Provider Demographics
NPI:1033759071
Name:BULLOCK, JARVIS PAUL
Entity Type:Individual
Prefix:MR
First Name:JARVIS
Middle Name:PAUL
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 METROPOLITAN AVE APT 5H
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-6147
Mailing Address - Country:US
Mailing Address - Phone:203-550-2309
Mailing Address - Fax:
Practice Address - Street 1:184 ELDRIDGE ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10002-2924
Practice Address - Country:US
Practice Address - Phone:212-674-9120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-07
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor