Healthcare Provider Details

I. General information

NPI: 1336084276
Provider Name (Legal Business Name): JESSICA FULLILOVE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2026
Last Update Date: 04/20/2026
Certification Date: 04/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3795 LINCOLN ST
GARY IN
46408-2115
US

IV. Provider business mailing address

3795 LINCOLN ST
GARY IN
46408-2115
US

V. Phone/Fax

Practice location:
  • Phone: 219-413-1727
  • Fax:
Mailing address:
  • Phone: 219-413-1727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number$$$$$$$$$
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: