Healthcare Provider Details

I. General information

NPI: 1174438386
Provider Name (Legal Business Name): JACOB FULTON SFIDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2026
Last Update Date: 08/14/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35000 GUADALCANAL ST
SAN DIEGO CA
92140-5599
US

IV. Provider business mailing address

34101 FARENHOLT AVE
SAN DIEGO CA
92134-7000
US

V. Phone/Fax

Practice location:
  • Phone: 814-516-1620
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: