Provider Demographics
NPI:1154476653
Name:BULLOCK, JACOB ANDREW (DC)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:ANDREW
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 W ZANDALE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-2486
Mailing Address - Country:US
Mailing Address - Phone:859-272-0099
Mailing Address - Fax:859-272-0073
Practice Address - Street 1:152 W ZANDALE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-2486
Practice Address - Country:US
Practice Address - Phone:859-272-0099
Practice Address - Fax:859-272-0073
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2013-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4918111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY85003333Medicaid
KY46-2164378OtherEIN
KY000000356740Medicare UPIN
KY46-2164378OtherEIN