Provider Demographics
NPI:1326520974
Name:FULCHER, JARED WHITFORD (PTA)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:WHITFORD
Last Name:FULCHER
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1690 CORE POINT RD
Mailing Address - Street 2:
Mailing Address - City:ERNUL
Mailing Address - State:NC
Mailing Address - Zip Code:28527-9503
Mailing Address - Country:US
Mailing Address - Phone:252-229-9596
Mailing Address - Fax:
Practice Address - Street 1:2600 OLD CHERRY POINT RD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28560-6778
Practice Address - Country:US
Practice Address - Phone:252-637-4730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-30
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCA6254225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant