Provider Demographics
NPI:1891791422
Name:SIMKINS-BULLOCK, JENNIFER A (PHD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:A
Last Name:SIMKINS-BULLOCK
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3949 SUNFOREST CT
Mailing Address - Street 2:STE 105
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43623-4454
Mailing Address - Country:US
Mailing Address - Phone:419-475-8809
Mailing Address - Fax:419-475-8810
Practice Address - Street 1:3949 SUNFOREST CT
Practice Address - Street 2:STE 105
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43623-4454
Practice Address - Country:US
Practice Address - Phone:419-475-8809
Practice Address - Fax:419-475-8810
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-28
Last Update Date:2008-11-03
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-22
Provider Licenses
StateLicense IDTaxonomies
OH4779103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHSICP15552Medicare ID - Type Unspecified
OHR72383Medicare UPIN