Provider Demographics
NPI:1336398551
Name:FULLER, JASON
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:FULLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 N MARY AVE
Mailing Address - Street 2:UNIT 59
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94086-4814
Mailing Address - Country:US
Mailing Address - Phone:904-866-0832
Mailing Address - Fax:
Practice Address - Street 1:2625 ZANKER RD
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95134-2130
Practice Address - Country:US
Practice Address - Phone:408-325-5116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-11
Last Update Date:2024-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)