Provider Demographics
NPI:1659932275
Name:FULGHAM, JARED AUSTIN (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:AUSTIN
Last Name:FULGHAM
Suffix:
Gender:M
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6410 OLD MAIN HL
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84322-6410
Mailing Address - Country:US
Mailing Address - Phone:435-797-1375
Mailing Address - Fax:844-308-5865
Practice Address - Street 1:6410 OLD MAIN HL
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84322-6410
Practice Address - Country:US
Practice Address - Phone:435-797-1375
Practice Address - Fax:844-308-5865
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9451387-4102235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT9451387-4102OtherSTATE LICENSE
IDSLP-3236OtherSTATE LICENSE