Provider Demographics
NPI:1891849147
Name:BULLOCK, JILLIAN (CNA 1)
Entity Type:Individual
Prefix:MS
First Name:JILLIAN
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:CNA 1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 311
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27536-0311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:815 SULPHUR SPRINGS RD
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:NC
Practice Address - Zip Code:27589
Practice Address - Country:US
Practice Address - Phone:252-433-8007
Practice Address - Fax:252-436-6008
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2019-08-16
Deactivation Date:2019-06-04
Deactivation Code:
Reactivation Date:2019-08-16
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide