Provider Demographics
NPI:1598246472
Name:BULLARD, JACQUELINE WENONA (PTA)
Entity Type:Individual
Prefix:MS
First Name:JACQUELINE
Middle Name:WENONA
Last Name:BULLARD
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MRS
Other - First Name:JACQUELINE
Other - Middle Name:WENONA
Other - Last Name:ANGERBAUER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:245 THORNTON RD
Mailing Address - Street 2:
Mailing Address - City:LOCKESBURG
Mailing Address - State:AR
Mailing Address - Zip Code:71846-9406
Mailing Address - Country:US
Mailing Address - Phone:405-962-8447
Mailing Address - Fax:
Practice Address - Street 1:245 THORNTON RD
Practice Address - Street 2:
Practice Address - City:LOCKESBURG
Practice Address - State:AR
Practice Address - Zip Code:71846-9406
Practice Address - Country:US
Practice Address - Phone:405-962-8447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-28
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2386225200000X
AR4330225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR229517721Medicaid