1649695610 NPI number — JESSICA BULLOCK LCADC, MA, CCS

Table of content: JESSICA BULLOCK LCADC, MA, CCS (NPI 1649695610)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649695610 NPI number — JESSICA BULLOCK LCADC, MA, CCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BULLOCK
Provider First Name:
JESSICA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LCADC, MA, CCS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649695610
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
821 N WOOD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LINDEN
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07036-4037
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-290-3550
Provider Business Mailing Address Fax Number:
732-626-6365

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2 SOUTH AVE E STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CRANFORD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07016-2811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
732-770-5627
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/26/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  37PC00529500 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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