Provider Demographics
NPI:1487900304
Name:FULMER, JENNA M (DPT)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:M
Last Name:FULMER
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:
Other - Last Name:MERCHANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:1100 ASHWOOD DR STE 1100
Mailing Address - Street 2:
Mailing Address - City:CANONSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15317-4981
Mailing Address - Country:US
Mailing Address - Phone:651-492-7022
Mailing Address - Fax:
Practice Address - Street 1:998 MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:BENTLEYVILLE
Practice Address - State:PA
Practice Address - Zip Code:15314-1100
Practice Address - Country:US
Practice Address - Phone:724-239-5777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-29
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD23777225100000X
225100000X
PAPT021799225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA102781395Medicaid