Provider Demographics
NPI:1922577378
Name:FULCHER, JORDAN LARUE (FNP-C)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:LARUE
Last Name:FULCHER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:JORDAN
Other - Middle Name:FULCHER
Other - Last Name:LUNDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:112 KINGS XING
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MS
Mailing Address - Zip Code:39046-5370
Mailing Address - Country:US
Mailing Address - Phone:601-919-5150
Mailing Address - Fax:888-240-6288
Practice Address - Street 1:3680 LAKELAND LN
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4707
Practice Address - Country:US
Practice Address - Phone:601-982-5055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-15
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903027363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily