Provider Demographics
NPI:1114015815
Name:BULLOCK, JONATHAN WILLIAM (DC)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:WILLIAM
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19600 LA GRANGE RD
Mailing Address - Street 2:
Mailing Address - City:MOKENA
Mailing Address - State:IL
Mailing Address - Zip Code:60448-9321
Mailing Address - Country:US
Mailing Address - Phone:708-478-3000
Mailing Address - Fax:
Practice Address - Street 1:19600 LA GRANGE RD
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-9321
Practice Address - Country:US
Practice Address - Phone:708-478-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2011-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-009659111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02232796OtherBLUE CROSS BLUE SHIELD
IL02232796OtherBLUE CROSS BLUE SHIELD
IL212454Medicare ID - Type Unspecified