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General NPI Number Information
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NPI Number | 1134520539
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Entity Type | Individual
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Provider Name | JARIAH FULSON ATC
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Gender | Female
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Dates
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Enumeration Date | 09/04/2014
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 2300 S 1ST ST
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City | CHAMPAIGN
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State | IL
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Zip | 61820-7661
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Country | US
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Telephone | --
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Fax |
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Provider Business Mailing Address
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Address Line | 406 E MICHIGAN AVE APT 1
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City | URBANA
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State | IL
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Zip | 61801-5061
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Country | US
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Telephone | 402-926-1874
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number |
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License Number State | NE
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Taxonomy #2
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 096004415
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License Number State | IL
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