Provider Demographics
NPI:1962927764
Name:BULLARD, JACQUELINE ELAINE (OD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ELAINE
Last Name:BULLARD
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 N JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62220-1425
Mailing Address - Country:US
Mailing Address - Phone:618-233-1270
Mailing Address - Fax:618-233-5939
Practice Address - Street 1:22 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:IL
Practice Address - Zip Code:62220-1425
Practice Address - Country:US
Practice Address - Phone:618-233-1270
Practice Address - Fax:618-233-5939
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL064011144152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist