Provider Demographics
NPI:1578199592
Name:FULLMER, JESSICA (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:FULLMER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 W 940 N
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3301
Mailing Address - Country:US
Mailing Address - Phone:801-357-7686
Mailing Address - Fax:
Practice Address - Street 1:475 W 940 N
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604-3301
Practice Address - Country:US
Practice Address - Phone:801-357-7686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-21
Last Update Date:2023-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5602710-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine