Provider Demographics
NPI:1629585229
Name:FULTON, JESSICA TIARA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:TIARA
Last Name:FULTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W 76TH AVE APT 105
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99518-2551
Mailing Address - Country:US
Mailing Address - Phone:907-306-4173
Mailing Address - Fax:
Practice Address - Street 1:1001 CHERRY ST UNIT A
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99504-2230
Practice Address - Country:US
Practice Address - Phone:907-306-4173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-04
Last Update Date:2018-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1011143104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness