Healthcare Provider Details

I. General information

NPI: 1336075894
Provider Name (Legal Business Name): JAMEIL FULLWOOD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2026
Last Update Date: 06/22/2026
Certification Date: 06/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

818 LONG DR APT 432
ABERDEEN MD
21001-1147
US

IV. Provider business mailing address

818 LONG DR APT 432
ABERDEEN MD
21001-1147
US

V. Phone/Fax

Practice location:
  • Phone: 443-240-6267
  • Fax:
Mailing address:
  • Phone: 443-240-6267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number10274026073
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: