Healthcare Provider Details

I. General information

NPI: 1053447649
Provider Name (Legal Business Name): JANA FULLER FERCHAUD OT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JANA REBECCA FULLER OT

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 05/24/2022
Certification Date: 05/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 STUBBS AVE
MONROE LA
71201-5629
US

IV. Provider business mailing address

105 EAGLE LAKE DR
WEST MONROE LA
71291-8753
US

V. Phone/Fax

Practice location:
  • Phone: 318-388-8414
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: