Provider Demographics
NPI:1407621758
Name:FULMER, JACQUELINE (MED)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:FULMER
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3011 ASPEN WAY
Mailing Address - Street 2:
Mailing Address - City:MELISSA
Mailing Address - State:TX
Mailing Address - Zip Code:75454-2649
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:720 E PARK BLVD STE 204
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75074-8802
Practice Address - Country:US
Practice Address - Phone:469-342-3468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-16
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health