Healthcare Provider Details

I. General information

NPI: 1114445897
Provider Name (Legal Business Name): JESSICA L FULTZ NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JESSICA L COPE

II. Dates (important events)

Enumeration Date: 09/01/2017
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 N RUTLEDGE ST FL 4
SPRINGFIELD IL
62702-6700
US

IV. Provider business mailing address

PO BOX 19639
SPRINGFIELD IL
62794-9639
US

V. Phone/Fax

Practice location:
  • Phone: 217-545-8000
  • Fax:
Mailing address:
  • Phone: 615-373-7600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.035650
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0024175078
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number0024175078
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: