Provider Demographics
NPI:1164537387
Name:FULLER, JASON P (DC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:P
Last Name:FULLER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3724 EXECUTIVE CENTER DR
Mailing Address - Street 2:SUITE G-10
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78731-1646
Mailing Address - Country:US
Mailing Address - Phone:512-345-5925
Mailing Address - Fax:512-343-7113
Practice Address - Street 1:3724 EXECUTIVE CENTER DR
Practice Address - Street 2:SUITE G-10
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78731-1646
Practice Address - Country:US
Practice Address - Phone:512-345-5925
Practice Address - Fax:512-343-7113
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX7137111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXU72263Medicare UPIN
TX82Y276Medicare ID - Type UnspecifiedMEDICARE