Provider Demographics
NPI:1649695610
Name:BULLOCK, JESSICA (LCADC, MA, CCS)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:
Credentials:LCADC, MA, CCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:821 N WOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LINDEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07036-4037
Mailing Address - Country:US
Mailing Address - Phone:908-290-3550
Mailing Address - Fax:732-626-6365
Practice Address - Street 1:2 SOUTH AVE E STE 200
Practice Address - Street 2:
Practice Address - City:CRANFORD
Practice Address - State:NJ
Practice Address - Zip Code:07016-2811
Practice Address - Country:US
Practice Address - Phone:732-770-5627
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-26
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00529500101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)