Provider Demographics
NPI:1417985227
Name:FULLMER, JASON MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:MICHAEL
Last Name:FULLMER
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 1:463 DELANCEY COURT
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17055
Mailing Address - Country:US
Mailing Address - Phone:717-460-3422
Mailing Address - Fax:717-796-2409
Practice Address - Street 1:21 NORTH 4TH STREET
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17101
Practice Address - Country:US
Practice Address - Phone:717-233-3476
Practice Address - Fax:717-796-2409
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA009494111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAFU1813015OtherHIGHMARK
PA50058252OtherCAPITAL BLUE CROSS
PAFU1813015OtherHIGHMARK
PA50058252OtherCAPITAL BLUE CROSS