Provider Demographics
NPI:1447340724
Name:FULLAM, JACQUELINE (MPT)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:FULLAM
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:866-370-8206
Mailing Address - Fax:517-435-3670
Practice Address - Street 1:2300 PLEASANT VALLEY RD
Practice Address - Street 2:
Practice Address - City:YORK
Practice Address - State:PA
Practice Address - Zip Code:17402-9627
Practice Address - Country:US
Practice Address - Phone:717-757-3537
Practice Address - Fax:717-718-9701
Is Sole Proprietor?:No
Enumeration Date:2006-10-15
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT015090225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
002004718OtherGEISINGER
1514688OtherADVANTRA
1592146OtherCOVENTRY NATIONAL / FIRST HEALTH
PA002004718OtherHIGHMARK BC BS
1514688OtherHEALTH AMERICA
1592146OtherCOVENTRY NATIONAL / FIRST HEALTH