Provider Demographics
NPI:1871247247
Name:BULLOCK, JEANETTE (ATR-BC)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:ATR-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 SILVERADO DR
Mailing Address - Street 2:
Mailing Address - City:BASALT
Mailing Address - State:CO
Mailing Address - Zip Code:81621-9232
Mailing Address - Country:US
Mailing Address - Phone:352-514-1625
Mailing Address - Fax:
Practice Address - Street 1:70 SILVERADO DR
Practice Address - Street 2:
Practice Address - City:BASALT
Practice Address - State:CO
Practice Address - Zip Code:81621-9232
Practice Address - Country:US
Practice Address - Phone:352-514-1625
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-04
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes221700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersArt Therapist