Provider Demographics
NPI:1558360198
Name:BULLOUGH, JERRY JAY (DC)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:JAY
Last Name:BULLOUGH
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 1:360 S FORT LN
Mailing Address - Street 2:STE 102
Mailing Address - City:LAYTON
Mailing Address - State:UT
Mailing Address - Zip Code:84041-4259
Mailing Address - Country:US
Mailing Address - Phone:801-546-3731
Mailing Address - Fax:801-546-3777
Practice Address - Street 1:360 S FORT LN
Practice Address - Street 2:STE 102
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-4259
Practice Address - Country:US
Practice Address - Phone:801-546-3731
Practice Address - Fax:801-546-3777
Is Sole Proprietor?:No
Enumeration Date:2005-07-15
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT165340-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor