Provider Demographics
NPI:1134290331
Name:FULLER, JASON (DPT)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:FULLER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 CROSS CREEK CT
Mailing Address - Street 2:APT B
Mailing Address - City:CENTRAL
Mailing Address - State:SC
Mailing Address - Zip Code:29630-4108
Mailing Address - Country:US
Mailing Address - Phone:931-261-5569
Mailing Address - Fax:
Practice Address - Street 1:12023 NORTH RADIO STATION RD.
Practice Address - Street 2:STE A
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-0929
Practice Address - Country:US
Practice Address - Phone:864-985-0770
Practice Address - Fax:864-985-1770
Is Sole Proprietor?:No
Enumeration Date:2006-11-11
Last Update Date:2007-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5295225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist