Provider Demographics
NPI:1649484999
Name:FULKS, JAIMIE
Entity type:Individual
Prefix:
First Name:JAIMIE
Middle Name:
Last Name:FULKS
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 1:8795 HASTINGS CIR NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-4508
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225 1ST AVE NE
Practice Address - Street 2:
Practice Address - City:OSSEO
Practice Address - State:MN
Practice Address - Zip Code:55369-1201
Practice Address - Country:US
Practice Address - Phone:763-424-0534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant