Provider Demographics
NPI:1982270088
Name:FULLER, JALISA
Entity type:Individual
Prefix:
First Name:JALISA
Middle Name:
Last Name:FULLER
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 1:1621 WILLIAMSBURG DR
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71112-3165
Mailing Address - Country:US
Mailing Address - Phone:318-730-2368
Mailing Address - Fax:
Practice Address - Street 1:1621 WILLIAMSBURG DR
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71112-3165
Practice Address - Country:US
Practice Address - Phone:318-730-2368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-28
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA009494849172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA843382246Medicaid