Provider Demographics
NPI:1386848174
Name:BULLOCK, JEFFREY MICHAEL (PT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:MICHAEL
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 JEWELL LN
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-9293
Mailing Address - Country:US
Mailing Address - Phone:270-534-8650
Mailing Address - Fax:
Practice Address - Street 1:544 LONE OAK RD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-4538
Practice Address - Country:US
Practice Address - Phone:270-443-6543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPT-004550225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist