Basic Information
| Provider Information | |||||||||
| NPI: | 1245674316 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SCOTT | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | LEE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 533 PARNASSUS AVENUE | ||||||||
| Address2: | SUITE U127, BOX 0131 | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4155142711 | ||||||||
| FaxNumber: | 4154764818 | ||||||||
| Practice Location | |||||||||
| Address1: | 533 PARNASSUS AVE STE U127 | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941432208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4155142711 | ||||||||
| FaxNumber: | 4154764818 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/19/2013 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 57.023142 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208000000X | 57.023142 | OH | N | Allopathic & Osteopathic Physicians | Pediatrics | 208M00000X | 202101856 | NC | Y | Allopathic & Osteopathic Physicians | Hospitalist |
No ID Information.