Healthcare Provider Details

I. General information

NPI: 1487900304
Provider Name (Legal Business Name): JENNA M FULMER DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNA MERCHANT DPT

II. Dates (important events)

Enumeration Date: 07/29/2012
Last Update Date: 12/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

998 MAIN ST STE B
BENTLEYVILLE PA
15314-1100
US

IV. Provider business mailing address

1100 ASHWOOD DR STE 1100
CANONSBURG PA
15317-4981
US

V. Phone/Fax

Practice location:
  • Phone: 724-239-5777
  • Fax:
Mailing address:
  • Phone: 651-492-7022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number23777
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT021799
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: