Provider Demographics
NPI:1679704613
Name:FULLERTON, JODIE L
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:L
Last Name:FULLERTON
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 1:208 N 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-2632
Mailing Address - Country:US
Mailing Address - Phone:509-965-5750
Mailing Address - Fax:509-965-8257
Practice Address - Street 1:208 N 3RD AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-2632
Practice Address - Country:US
Practice Address - Phone:509-965-5750
Practice Address - Fax:509-965-8257
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00016698174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist