Provider Demographics
NPI:1265668446
Name:FULLER, JENNIFER ELIZABETH (PT)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ELIZABETH
Last Name:FULLER
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ELIZABETH
Other - Last Name:STOECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:1600 MAIN ST FL 2
Mailing Address - Street 2:
Mailing Address - City:VENICE
Mailing Address - State:CA
Mailing Address - Zip Code:90291-3626
Mailing Address - Country:US
Mailing Address - Phone:888-859-0145
Mailing Address - Fax:888-858-1601
Practice Address - Street 1:6080 CENTER DR.
Practice Address - Street 2:6TH FLOOR SUITE # 639
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-9205
Practice Address - Country:US
Practice Address - Phone:888-859-0145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-02
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60044173225100000X
CA296647225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist