Healthcare Provider Details

I. General information

NPI: 1891791422
Provider Name (Legal Business Name): JENNIFER A. SIMKINS-BULLOCK PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2005
Last Update Date: 11/03/2008
Certification Date:
Deactivation Date: 03/17/2006
Reactivation Date: 03/22/2006

III. Provider practice location address

3949 SUNFOREST CT STE 105
TOLEDO OH
43623-4454
US

IV. Provider business mailing address

3949 SUNFOREST CT STE 105
TOLEDO OH
43623-4454
US

V. Phone/Fax

Practice location:
  • Phone: 419-475-8809
  • Fax: 419-475-8810
Mailing address:
  • Phone: 419-475-8809
  • Fax: 419-475-8810

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number4779
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: