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General NPI Number Information
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NPI Number | 1851583405
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Entity Type | Individual
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Provider Name | JESSICA ANGELIC BULLWINKLE LMFT
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Gender | Female
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Dates
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Enumeration Date | 08/16/2007
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Last Update Date | 08/24/2021
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Provider Practice Location Address
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Address Line | 17705 HALE AVE STE F4
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City | MORGAN HILL
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State | CA
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Zip | 95037-4349
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Country | US
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Telephone | 408-599-9562
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Fax | 408-413-0462
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Provider Business Mailing Address
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Address Line | 2618 E SNOCREEK DR
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City | EAGLE
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State | ID
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Zip | 83616-5816
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Country | US
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Telephone | 408-599-9562
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Fax | 408-350-2021
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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 | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | MFC49357
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | LMFT-7472
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License Number State | ID
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