Healthcare Provider Details

I. General information

NPI: 1225154735
Provider Name (Legal Business Name): JENNIFER BHULLAR PT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2007
Last Update Date: 01/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4776 HODGES BLVD STE 101
JACKSONVILLE FL
32224-7217
US

IV. Provider business mailing address

4776 HODGES BLVD STE 101
JACKSONVILLE FL
32224-7218
US

V. Phone/Fax

Practice location:
  • Phone: 904-223-2363
  • Fax:
Mailing address:
  • Phone: 904-223-2363
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT 23035
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPT23035
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: