Provider Demographics
NPI:1427547355
Name:FULFORD, JERRY WALLACE
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:WALLACE
Last Name:FULFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4170 GROSS RD. EXTENSION
Mailing Address - Street 2:SUITE 6
Mailing Address - City:CAPITOLA
Mailing Address - State:CA
Mailing Address - Zip Code:95010
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4170 GROSS RD. EXTENSION
Practice Address - Street 2:SUITE 6
Practice Address - City:CAPITOLA
Practice Address - State:CA
Practice Address - Zip Code:95010
Practice Address - Country:US
Practice Address - Phone:831-464-1605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-07
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA75622225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist