Healthcare Provider Details

I. General information

NPI: 1164537387
Provider Name (Legal Business Name): JASON P. FULLER D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3724 EXECUTIVE CENTER DR SUITE G-10
AUSTIN TX
78731-1646
US

IV. Provider business mailing address

3724 EXECUTIVE CENTER DR SUITE G-10
AUSTIN TX
78731-1646
US

V. Phone/Fax

Practice location:
  • Phone: 512-345-5925
  • Fax: 512-343-7113
Mailing address:
  • Phone: 512-345-5925
  • Fax: 512-343-7113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number7137
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: