Healthcare Provider Details

I. General information

NPI: 1639019474
Provider Name (Legal Business Name): JESSICA FULLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2026
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

736 W LINCOLN HWY
EXTON PA
19341-2547
US

IV. Provider business mailing address

130 MONUMENT RD APT 507
BALA CYNWYD PA
19004-1765
US

V. Phone/Fax

Practice location:
  • Phone: 484-999-2100
  • Fax:
Mailing address:
  • Phone: 973-997-6110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN749550
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: