Provider Demographics
NPI:1992093215
Name:BULLOCK, SONJA P (LCSW)
Entity type:Individual
Prefix:
First Name:SONJA
Middle Name:P
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:508 CEDARWOOD DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39212-2220
Mailing Address - Country:US
Mailing Address - Phone:601-214-8157
Mailing Address - Fax:601-371-0905
Practice Address - Street 1:508 CEDARWOOD DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39212-2220
Practice Address - Country:US
Practice Address - Phone:601-214-8157
Practice Address - Fax:601-371-0905
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-20
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC49371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical