Provider Demographics
NPI:1457005365
Name:BULLOCK, JESSE
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13191 KELLAM CT APT 95
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-1279
Mailing Address - Country:US
Mailing Address - Phone:775-901-6190
Mailing Address - Fax:
Practice Address - Street 1:2271 ALPINE BLVD STE A
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:CA
Practice Address - Zip Code:91901-1101
Practice Address - Country:US
Practice Address - Phone:619-289-7322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health