Provider Demographics
NPI:1083144828
Name:FULLERTON, JACQUELINE NICOLE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:NICOLE
Last Name:FULLERTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 STURBRIDGE CT
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:MD
Mailing Address - Zip Code:21013-9600
Mailing Address - Country:US
Mailing Address - Phone:443-504-3315
Mailing Address - Fax:
Practice Address - Street 1:167 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:TUBA CITY
Practice Address - State:AZ
Practice Address - Zip Code:86045
Practice Address - Country:US
Practice Address - Phone:928-283-2590
Practice Address - Fax:928-283-2591
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2017-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist