Provider Demographics
NPI:1346287976
Name:BULLOCK, JENNIFER ZANE (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ZANE
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 933377
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0038
Mailing Address - Country:US
Mailing Address - Phone:614-635-9606
Mailing Address - Fax:
Practice Address - Street 1:170 NORTHWOODS BLVD STE 120
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235-4711
Practice Address - Country:US
Practice Address - Phone:614-635-9606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-08-2026207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2632628Medicaid
OHBU4182151Medicare PIN
OH2632628Medicaid