Healthcare Provider Details

I. General information

NPI: 1538079223
Provider Name (Legal Business Name): JARED I BULLUCK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1797 HILL RD N STE 101
PICKERINGTON OH
43147-7997
US

IV. Provider business mailing address

2122 YORK RD STE 300
OAK BROOK IL
60523-1925
US

V. Phone/Fax

Practice location:
  • Phone: 614-494-0140
  • Fax: 614-494-0141
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT022633
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: