Provider Demographics
NPI:1831483569
Name:BULLOCK, JANET M (RD)
Entity Type:Individual
Prefix:MS
First Name:JANET
Middle Name:M
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:950 MATTHEW DR
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:MS
Mailing Address - Zip Code:39367-2567
Mailing Address - Country:US
Mailing Address - Phone:601-735-5151
Mailing Address - Fax:601-735-7168
Practice Address - Street 1:950 MATTHEW DR
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:MS
Practice Address - Zip Code:39367-2567
Practice Address - Country:US
Practice Address - Phone:601-735-5151
Practice Address - Fax:601-735-7168
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-28
Last Update Date:2011-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSD1269133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSD1269OtherSTATE LICENSE