Basic Information
| Provider Information | |||||||||
| NPI: | 1811980964 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BULMANN | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 W PETERSON AVE | ||||||||
| Address2: | STE 401 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606593306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7735883090 | ||||||||
| FaxNumber: | 7735883210 | ||||||||
| Practice Location | |||||||||
| Address1: | 3500 W PETERSON AVE | ||||||||
| Address2: | STE 401 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606593306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7735883090 | ||||||||
| FaxNumber: | 7735883210 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2005 | ||||||||
| LastUpdateDate: | 12/22/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 2163 | TN | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 2011037755 | MO | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 046009248 | IL | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 3946149 | 05 | TN | MEDICAID | P01342597 | 01 | IL | RAILROAD MEDICARE NUMBER | OTHER | 1811980964 | 05 | MO | MEDICAID | 2163 | 01 | TN | OD | OTHER | MB1096646 | 01 | DEA | OTHER |