Provider Demographics
NPI:1992186621
Name:FULLER, JENNIFER (MED)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 NAZARETH PIKE
Mailing Address - Street 2:TROLLEY STATION MALL SUITE 22A
Mailing Address - City:BETHLEHEM
Mailing Address - State:PA
Mailing Address - Zip Code:18020-9080
Mailing Address - Country:US
Mailing Address - Phone:610-365-8373
Mailing Address - Fax:610-365-2522
Practice Address - Street 1:224 NAZARETH PIKE
Practice Address - Street 2:TROLLEY STATION MALL SUITE 22A
Practice Address - City:BETHLEHEM
Practice Address - State:PA
Practice Address - Zip Code:18020-9080
Practice Address - Country:US
Practice Address - Phone:610-365-8373
Practice Address - Fax:610-365-2522
Is Sole Proprietor?:No
Enumeration Date:2015-06-18
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PABH002796103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst