Provider Demographics
NPI:1528523842
Name:BULLOCK, JASMINE LA'TESE (LMSW)
Entity type:Individual
Prefix:
First Name:JASMINE
Middle Name:LA'TESE
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11173 LILLIAN AVE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48089-3570
Mailing Address - Country:US
Mailing Address - Phone:586-744-0091
Mailing Address - Fax:
Practice Address - Street 1:26300 OUTER DR
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-2019
Practice Address - Country:US
Practice Address - Phone:313-388-4630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-01
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801096690104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical