Provider Demographics
NPI:1750823530
Name:BULLOCK, JESSICA (PMHNP, RN)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:PMHNP, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4831 RIVERVALE DR
Mailing Address - Street 2:
Mailing Address - City:SOQUEL
Mailing Address - State:CA
Mailing Address - Zip Code:95073-9727
Mailing Address - Country:US
Mailing Address - Phone:503-884-6518
Mailing Address - Fax:
Practice Address - Street 1:4850 UNION AVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-5156
Practice Address - Country:US
Practice Address - Phone:800-913-2615
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-10
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201242077RN163W00000X
CA95146518163W00000X
CA95019999363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse