Provider Demographics
NPI:1871576744
Name:FULLER, JILL C (MD)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:C
Last Name:FULLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 POWELL AVE SW
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057-2908
Mailing Address - Country:US
Mailing Address - Phone:425-277-1311
Mailing Address - Fax:
Practice Address - Street 1:33431 13TH PL S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6357
Practice Address - Country:US
Practice Address - Phone:253-874-7634
Practice Address - Fax:253-874-7635
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001912207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine