Provider Demographics
NPI:1376926352
Name:FULLER, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3205 OX MEADOW CT
Mailing Address - Street 2:
Mailing Address - City:OAK HILL
Mailing Address - State:VA
Mailing Address - Zip Code:20171-1747
Mailing Address - Country:US
Mailing Address - Phone:703-626-2412
Mailing Address - Fax:
Practice Address - Street 1:7503 SURRATTS RD
Practice Address - Street 2:MEDSTAR SOUTHERN MD HOSPITAL CENTER EMERGENCY DEPT
Practice Address - City:CLINTON
Practice Address - State:MD
Practice Address - Zip Code:20735-3358
Practice Address - Country:US
Practice Address - Phone:301-868-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-08
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0005818363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant