Provider Demographics
NPI:1194063123
Name:BULLOCK, JODI C (RD, CLT)
Entity type:Individual
Prefix:
First Name:JODI
Middle Name:C
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:RD, CLT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4825 EP TRUE PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50265-6403
Mailing Address - Country:US
Mailing Address - Phone:515-226-3468
Mailing Address - Fax:
Practice Address - Street 1:4825 EP TRUE PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50265-6403
Practice Address - Country:US
Practice Address - Phone:515-226-3468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-25
Last Update Date:2013-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered