Provider Demographics
NPI:1902344468
Name:BULLOCK, JESSICA MARIE (DPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:MARIE
Other - Last Name:STEVENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:408 JOAN DR
Mailing Address - Street 2:
Mailing Address - City:OLYPHANT
Mailing Address - State:PA
Mailing Address - Zip Code:18447-2178
Mailing Address - Country:US
Mailing Address - Phone:570-606-7694
Mailing Address - Fax:
Practice Address - Street 1:408 JOAN DR
Practice Address - Street 2:
Practice Address - City:OLYPHANT
Practice Address - State:PA
Practice Address - Zip Code:18447-2178
Practice Address - Country:US
Practice Address - Phone:570-606-7694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-05
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT021690225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist