Provider Demographics
NPI:1922297613
Name:BULLOCK, JEFFREY DALE (PT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:DALE
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:PT
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 160
Mailing Address - Street 2:
Mailing Address - City:SHIPROCK
Mailing Address - State:NM
Mailing Address - Zip Code:87420-0160
Mailing Address - Country:US
Mailing Address - Phone:505-368-6001
Mailing Address - Fax:505-368-7091
Practice Address - Street 1:US HWY 491 NORTH
Practice Address - Street 2:
Practice Address - City:SHIPROCK
Practice Address - State:NM
Practice Address - Zip Code:87420
Practice Address - Country:US
Practice Address - Phone:505-368-6001
Practice Address - Fax:505-368-7091
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-17
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0011340225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist