Provider Demographics
NPI:1083783609
Name:FULTON, JENNIFER CARROLL (MD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:CARROLL
Last Name:FULTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 SAN MARCO BLVD STE 300
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8567
Mailing Address - Country:US
Mailing Address - Phone:904-253-6910
Mailing Address - Fax:904-253-6964
Practice Address - Street 1:1325 SAN MARCO BLVD STE 300
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8567
Practice Address - Country:US
Practice Address - Phone:904-253-6910
Practice Address - Fax:904-253-6964
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2022-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME104269207R00000X, 207RC0200X, 207RP1001X
FLME 104269207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004352900Medicaid
FL331202OtherAVMED
FL59-3385828OtherTAX ID FOR OTHER INSURANCES
FL7434827OtherAETNA
FLP00194320OtherMEDICARE RAILROAD
FL149S0OtherBCBS
FL004352900Medicaid