MEDICARE: DR. JERRY JAY BULLOUGH D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	165340-1202	UT

General Provider Information

NPI Number	:	1558360198
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JERRY JAY BULLOUGH D.C.

Provider Business Mailing Address
First Line	:	360 S FORT LN
Second Line	:	STE 102
City	:	LAYTON
State	:	UT
Zip	:	84041-4259
Country	:	US
Telephone Number	:	801-546-3731
Fax Number	:	801-546-3777

Provider Business Practice Location Address
First Line	:	360 S FORT LN
Second Line	:	STE 102
City	:	LAYTON
State	:	UT
Zip	:	84041-4259
Country	:	US
Telephone Number	:	801-546-3731
Fax Number	:	801-546-3777

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/15/2005
Last Update Date	:	10/28/2008

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