Provider Demographics
NPI:1447784079
Name:FULTON, JESSICA E
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:E
Last Name:FULTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3301 E 12TH ST STE 259
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-2940
Mailing Address - Country:US
Mailing Address - Phone:617-417-0014
Mailing Address - Fax:
Practice Address - Street 1:3301 E. 12TH STREET
Practice Address - Street 2:SUITE 259
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601
Practice Address - Country:US
Practice Address - Phone:510-269-9030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-20
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program