Provider Demographics
NPI:1124567631
Name:FULTON, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:FULTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 POINT RUN DR
Mailing Address - Street 2:
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78660-3827
Mailing Address - Country:US
Mailing Address - Phone:254-239-4342
Mailing Address - Fax:
Practice Address - Street 1:15300 FM 1825
Practice Address - Street 2:B101
Practice Address - City:PFLUGERVILLE
Practice Address - State:TX
Practice Address - Zip Code:78660-2603
Practice Address - Country:US
Practice Address - Phone:512-202-3686
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-16
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency