Individual
MR. JACOB DEAN FULLER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LPN
Contact information
Practice address
3333 RIVERBEND DR, SPRINGFIELD, OR 97477-8800
(877) 350-7430
Mailing address
585 36TH ST, SPRINGFIELD, OR 97478-5789
(541) 513-5518
Taxonomy
Speciality
Code
Description
License number
State
164W00000X
Licensed Practical Nurse
Primary
201230678LPN
OR
164W00000X
Licensed Practical Nurse
28704
WV
Other
Enumeration date
05/07/2013
Last updated
05/07/2013
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