Provider Demographics
NPI:1154517597
Name:FULLER, JEAN MARIE C (PT, DPT)
Entity type:Individual
Prefix:MRS
First Name:JEAN MARIE
Middle Name:C
Last Name:FULLER
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-4280
Mailing Address - Country:US
Mailing Address - Phone:321-727-2707
Mailing Address - Fax:321-727-2977
Practice Address - Street 1:408 5TH AVE
Practice Address - Street 2:
Practice Address - City:INDIALANTIC
Practice Address - State:FL
Practice Address - Zip Code:32903-4280
Practice Address - Country:US
Practice Address - Phone:321-727-2707
Practice Address - Fax:321-727-2977
Is Sole Proprietor?:No
Enumeration Date:2007-09-19
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT-23569225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist