Healthcare Provider Details

I. General information

NPI: 1942011267
Provider Name (Legal Business Name): JESSICA P FULLER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2025
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12216 W BROAD ST STE 4B-5
HENRICO VA
23233-1062
US

IV. Provider business mailing address

PO BOX 715868
PHILADELPHIA PA
19171-5868
US

V. Phone/Fax

Practice location:
  • Phone: 804-440-4878
  • Fax: 804-200-7124
Mailing address:
  • Phone: 804-915-1910
  • Fax: 804-968-1803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110010726
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: