Provider Demographics
NPI:1659525228
Name:BULLEN, KEZZIA JANE
Entity Type:Individual
Prefix:
First Name:KEZZIA
Middle Name:JANE
Last Name:BULLEN
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 1:220 FIG ST
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95678-2512
Mailing Address - Country:US
Mailing Address - Phone:530-320-3925
Mailing Address - Fax:
Practice Address - Street 1:900 FULTON AVE
Practice Address - Street 2:SUITE
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-9582
Practice Address - Country:US
Practice Address - Phone:916-216-1047
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-10
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA295481041C0700X
104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical