Basic Information
| Provider Information | |||||||||
| NPI: | 1083144828 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULLERTON | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 STURBRIDGE CT | ||||||||
| Address2: | |||||||||
| City: | BALDWIN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210139600 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4435043315 | ||||||||
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| Practice Location | |||||||||
| Address1: | 167 NORTH MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | TUBA CITY | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 86045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9282832590 | ||||||||
| FaxNumber: | 9282832591 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2017 | ||||||||
| LastUpdateDate: | 06/14/2017 | ||||||||
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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 | 225X00000X | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.