Provider Demographics
NPI:1982333431
Name:BULLOCK, JACQUELINE YVONNE
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:YVONNE
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 TREADWICK DR # 5653
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30350-5653
Mailing Address - Country:US
Mailing Address - Phone:470-514-5954
Mailing Address - Fax:
Practice Address - Street 1:155 TREADWICK DR # 5653
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30350-5653
Practice Address - Country:US
Practice Address - Phone:470-514-5954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-09
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNCN001423501163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Single Specialty