Provider Demographics
NPI:1063650406
Name:BULLOCK, JAYLA SNIPES (SLP)
Entity Type:Individual
Prefix:
First Name:JAYLA
Middle Name:SNIPES
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 3306
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31534-3306
Mailing Address - Country:US
Mailing Address - Phone:912-389-0077
Mailing Address - Fax:912-389-0997
Practice Address - Street 1:618 BOWENS MILL ROAD SW
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533
Practice Address - Country:US
Practice Address - Phone:912-389-0077
Practice Address - Fax:912-389-0997
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-22
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP005166235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist