Basic Information
| Provider Information | |||||||||
| NPI: | 1902149933 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FULLER | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | CARROLL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11234 ANDERSON ST # 2586A | ||||||||
| Address2: | |||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923542804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095587884 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11234 ANDERSON ST # 2586A | ||||||||
| Address2: | |||||||||
| City: | LOMA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923542804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095587884 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2013 | ||||||||
| LastUpdateDate: | 07/10/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 63479 | MN | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207YX0905X | A160366 | CA | Y | Allopathic & Osteopathic Physicians | Otolaryngology | Otolaryngology/Facial Plastic Surgery |
No ID Information.