Provider Demographics
NPI:1043960784
Name:FULTON, JESSICA ANN (MD)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANN
Last Name:FULTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:ANN
Other - Last Name:WALDEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:314 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:41011-1344
Mailing Address - Country:US
Mailing Address - Phone:937-244-8346
Mailing Address - Fax:
Practice Address - Street 1:314 W 7TH ST
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:KY
Practice Address - Zip Code:41011-1344
Practice Address - Country:US
Practice Address - Phone:937-244-8346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2025-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH28311246RP1900X
OH401994130817376K00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH500116992OtherOHIO STATE STUDENT ID
OH401994130817OtherSTATE TESTED NURSING ASSISTANT, NURSE AID