Healthcare Provider Details

I. General information

NPI: 1629991948
Provider Name (Legal Business Name): JACKSON BULLARD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2026
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2101 CAMBRIDGE BELTWAY DR STE E
CHARLOTTE NC
28273-4351
US

IV. Provider business mailing address

7122 ASBURY VILLAGE LN
HUNTERSVILLE NC
28078-5159
US

V. Phone/Fax

Practice location:
  • Phone: 615-560-6622
  • Fax:
Mailing address:
  • Phone: 704-560-3059
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-381450
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: