Healthcare Provider Details

I. General information

NPI: 1992214803
Provider Name (Legal Business Name): JORDAN LOUIS FULLER PT, DPT, LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2017
Last Update Date: 11/10/2022
Certification Date: 11/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 WINTER ST
WALTHAM MA
02451-1433
US

IV. Provider business mailing address

50 OCEAN AVE APT 513A
REVERE MA
02151-3897
US

V. Phone/Fax

Practice location:
  • Phone: 781-487-9944
  • Fax:
Mailing address:
  • Phone: 916-337-4524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number3209
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number26548
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: