Provider Demographics
NPI:1760908586
Name:BULLARD, JEFFERSON LEE (LCSW)
Entity Type:Individual
Prefix:
First Name:JEFFERSON
Middle Name:LEE
Last Name:BULLARD
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1141 TITAN ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-5001
Mailing Address - Country:US
Mailing Address - Phone:215-205-1004
Mailing Address - Fax:
Practice Address - Street 1:1348 BAINBRIDGE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-1810
Practice Address - Country:US
Practice Address - Phone:215-563-0652
Practice Address - Fax:215-563-0748
Is Sole Proprietor?:No
Enumeration Date:2017-08-15
Last Update Date:2017-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0194481041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical