Provider Demographics
NPI:1679233928
Name:FULLERTON, JESSLYN RENAY (ATRIC, AEAC)
Entity Type:Individual
Prefix:
First Name:JESSLYN
Middle Name:RENAY
Last Name:FULLERTON
Suffix:
Gender:F
Credentials:ATRIC, AEAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1012 ALBEMARLE ST
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701-4514
Mailing Address - Country:US
Mailing Address - Phone:304-952-6300
Mailing Address - Fax:
Practice Address - Street 1:1012 ALBEMARLE ST
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701-4514
Practice Address - Country:US
Practice Address - Phone:304-952-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-28
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation TherapistGroup - Single Specialty