Organization
STATE OF MISSOURI
Active
Parent organization
STATE OF MISSOURI
Other names
Fulton State Hospital
Organization subpart
Yes
Provider details
NPI number
Legal business name
STATE OF MISSOURI
Authorized official
MOLLY JANE BOECKMANN (DIRECTOR OF ADMINISTRATIVE SERVICES)
(573) 751-4055
Entity
Organization
Contact information
Practice address
600 E 5TH ST, FULTON, MO 65251-1753
(573) 592-4100
(573) 592-3000
Mailing address
1706 E ELM ST, PO BOX 687, JEFFERSON CITY, MO 65101-4130
(573) 751-3398
(573) 526-4560
Taxonomy
Speciality
Code
Description
License number
State
103T00000X
Psychologist
—
—
103TC0700X
Clinical Psychologist
—
—
1041C0700X
Clinical Social Worker
—
—
152W00000X
Optometrist
—
—
207Q00000X
Family Medicine Physician
—
—
207R00000X
Internal Medicine Physician
—
—
2084P0800X
Psychiatry Physician
Primary
—
—
213E00000X
Podiatrist
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
500490008
—
MO
Enumeration date
05/23/2006
Last updated
08/28/2020
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