Provider Demographics
NPI:1609262278
Name:BULLOCK, JESSICA ELAINE (NP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ELAINE
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1881 NANI ST
Mailing Address - Street 2:
Mailing Address - City:WAILUKU
Mailing Address - State:HI
Mailing Address - Zip Code:96793-1811
Mailing Address - Country:US
Mailing Address - Phone:808-871-7772
Mailing Address - Fax:
Practice Address - Street 1:50 CROSS PARK CT
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4263
Practice Address - Country:US
Practice Address - Phone:864-797-7035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-10
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19423363L00000X
HI2240363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP3164Medicaid
SCSC5667Medicare PIN