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NPI Code Detail

MEDICARE: JENNIFER ROSE FULTON BA

MEDICARE: JENNIFER ROSE FULTON BA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1106S00000XBehavior Technician

General Provider Information

NPI Number : 1568947174
Entity Type Code : Individual
Provider Name (Legal Business Name) : JENNIFER ROSE FULTON BA
Provider Business Mailing Address
First Line : 160 WIKIUP DR STE 102
Second Line :
City : SANTA ROSA
State : CA
Zip : 95403-7776
Country : US
Telephone Number : 707-308-2120
Fax Number :
Provider Business Practice Location Address
First Line : 160 WIKIUP DR STE 102
Second Line :
City : SANTA ROSA
State : CA
Zip : 95403-7776
Country : US
Telephone Number : 707-308-2120
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/28/2018
Last Update Date : 09/28/2018

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Directions to “ JENNIFER ROSE FULTON BA” Practice Location

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