Provider Demographics
NPI:1043960784
Name:FULTON, JESSICA (BS)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:FULTON
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8281 JONES RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH VIENNA
Mailing Address - State:OH
Mailing Address - Zip Code:45369-9549
Mailing Address - Country:US
Mailing Address - Phone:937-568-4011
Mailing Address - Fax:
Practice Address - Street 1:370 W 9TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1238
Practice Address - Country:US
Practice Address - Phone:937-244-8346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH28311246RP1900X
OH401994130817376K00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH401994130817OtherSTATE TESTED NURSING ASSISTANT, NURSE AID
OH500116992OtherOHIO STATE STUDENT ID