Healthcare Provider Details

I. General information

NPI: 1982333431
Provider Name (Legal Business Name): MRS. JACQUELINE YVONNE BULLOCK
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/09/2022
Last Update Date: 06/09/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 TREADWICK DR # 5653
ATLANTA GA
30350-5653
US

IV. Provider business mailing address

155 TREADWICK DR # 5653
ATLANTA GA
30350-5653
US

V. Phone/Fax

Practice location:
  • Phone: 470-514-5954
  • Fax:
Mailing address:
  • Phone: 470-514-5954
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberCN001423501
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: