Healthcare Provider Details

I. General information

NPI: 1457029175
Provider Name (Legal Business Name): JENNIFER FULLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2021
Last Update Date: 08/30/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

763 E 5TH ST
ONTARIO CA
91764-2439
US

IV. Provider business mailing address

763 E 5TH ST
ONTARIO CA
91764-2439
US

V. Phone/Fax

Practice location:
  • Phone: 714-321-8928
  • Fax:
Mailing address:
  • Phone: 714-321-8928
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number86358
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: