Provider Demographics
NPI:1427219294
Name:FULLER, JENNIFER JO (PHARMD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JO
Last Name:FULLER
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 A ST NW
Mailing Address - Street 2:
Mailing Address - City:LINTON
Mailing Address - State:IN
Mailing Address - Zip Code:47441-1801
Mailing Address - Country:US
Mailing Address - Phone:812-847-1978
Mailing Address - Fax:812-847-1985
Practice Address - Street 1:60 A ST NW
Practice Address - Street 2:
Practice Address - City:LINTON
Practice Address - State:IN
Practice Address - Zip Code:47441-1801
Practice Address - Country:US
Practice Address - Phone:812-847-1978
Practice Address - Fax:812-847-1985
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26022758A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN26022758AOtherPHARMACIST LICENSE