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General NPI Number Information
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NPI Number | 1992214803
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Entity Type | Individual
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Provider Name | JORDAN LOUIS FULLER PT, DPT, LAT, ATC
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Gender | Male
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Dates
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Enumeration Date | 09/22/2017
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Last Update Date | 11/10/2022
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Provider Practice Location Address
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Address Line | 840 WINTER ST
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City | WALTHAM
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State | MA
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Zip | 02451-1433
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Country | US
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Telephone | 781-487-9944
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Fax |
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Provider Business Mailing Address
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Address Line | 50 OCEAN AVE APT 513A
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City | REVERE
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State | MA
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Zip | 02151-3897
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Country | US
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Telephone | 916-337-4524
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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 | 2081S0010X
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Taxonomy Name | Sports Medicine (Physical Medicine & Rehabilitation) Physician
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License Number | 3209
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License Number State | MA
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Taxonomy #2
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 26548
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License Number State | MA
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