Basic Information
| Provider Information | |||||||||
| NPI: | 1366427676 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULTZ | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | DC PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3245 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | JUNEAU | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998017809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074636682 | ||||||||
| FaxNumber: | 9074636648 | ||||||||
| Practice Location | |||||||||
| Address1: | 3245 HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | JUNEAU | ||||||||
| State: | AK | ||||||||
| PostalCode: | 998017809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9074636682 | ||||||||
| FaxNumber: | 9074636648 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2005 | ||||||||
| LastUpdateDate: | 08/14/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 857 | VA | N | Chiropractic Providers | Chiropractor | 225100000X | 1694 | NM | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 2639 | AK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 446551 | 05 | AZ | MEDICAID | 93438061 | 05 | NM | MEDICAID | 29783739 | 05 | CO | MEDICAID |