Provider Demographics
NPI:1851583405
Name:BULLWINKLE, JESSICA ANGELIC (LMFT)
Entity Type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:ANGELIC
Last Name:BULLWINKLE
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2618 E SNOCREEK DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5816
Mailing Address - Country:US
Mailing Address - Phone:408-599-9562
Mailing Address - Fax:408-350-2021
Practice Address - Street 1:17705 HALE AVE STE F4
Practice Address - Street 2:
Practice Address - City:MORGAN HILL
Practice Address - State:CA
Practice Address - Zip Code:95037-4349
Practice Address - Country:US
Practice Address - Phone:408-599-9562
Practice Address - Fax:408-413-0462
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-16
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC49357106H00000X
IDLMFT-7472106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty