Healthcare Provider Details

I. General information

NPI: 1124381421
Provider Name (Legal Business Name): JASON MICHAEL BULLOCK D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2012
Last Update Date: 06/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4200A TECHNOLOGY CT
CHANTILLY VA
20151-1214
US

IV. Provider business mailing address

4200A TECHNOLOGY CT
CHANTILLY VA
20151-1214
US

V. Phone/Fax

Practice location:
  • Phone: 571-528-9796
  • Fax:
Mailing address:
  • Phone: 571-528-9796
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0104557050
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: