Healthcare Provider Details

I. General information

NPI: 1801563556
Provider Name (Legal Business Name): JEREMIAH BULLARD LPCA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2021
Last Update Date: 04/17/2026
Certification Date: 04/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 BARTON MILL RD APT 2H
CORBIN KY
40701-2921
US

IV. Provider business mailing address

113 BARTON MILL RD APT 2H
CORBIN KY
40701-2921
US

V. Phone/Fax

Practice location:
  • Phone: 606-627-3595
  • Fax: 606-385-1853
Mailing address:
  • Phone: 606-627-3595
  • Fax: 606-385-1853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number304165
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: