Provider Demographics
NPI:1326226465
Name:BULLOCK, JENNIFER ASHBY (LCSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ASHBY
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6220 CABIN BRANCH DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27712-9089
Mailing Address - Country:US
Mailing Address - Phone:919-741-0726
Mailing Address - Fax:919-479-8172
Practice Address - Street 1:1318 BROAD ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-3533
Practice Address - Country:US
Practice Address - Phone:919-741-0726
Practice Address - Fax:919-479-8172
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-31
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0043531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6002827Medicaid