Provider Demographics
NPI:1386906709
Name:BULLOCK, JEREMY (PT)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:BULLOCK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3325 ADAM LN
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75402-3329
Mailing Address - Country:US
Mailing Address - Phone:903-513-4629
Mailing Address - Fax:
Practice Address - Street 1:209 E BROADWAY ST
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:TX
Practice Address - Zip Code:75494-2604
Practice Address - Country:US
Practice Address - Phone:903-342-6790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1124014225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist