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General NPI Number Information
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NPI Number | 1497632293
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Entity Type | Individual
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Provider Name | JACOB BULLOCK
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Gender | Male
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Dates
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Enumeration Date | 08/21/2025
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Last Update Date | 10/05/2025
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Provider Practice Location Address
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Address Line | 3260 SEEBA LN
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City | GARBERVILLE
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State | CA
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Zip | 95542-9742
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Country | US
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Telephone | 707-298-4176
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 395
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City | MIRANDA
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State | CA
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Zip | 95553-0395
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 172A00000X
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Taxonomy Name | Driver
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License Number | B3385616
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 343900000X
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Taxonomy Name | Non-emergency Medical Transport (VAN)
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License Number |
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License Number State | CA
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