Individual
JORDAN LOUIS FULLER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PT, DPT, LAT, ATC
Contact information
Practice address
840 WINTER ST, WALTHAM, MA 02451-1433
(781) 487-9944
Mailing address
50 OCEAN AVE APT 513A, REVERE, MA 02151-3897
(916) 337-4524
Taxonomy
Speciality
Code
Description
License number
State
2081S0010X
Sports Medicine (Physical Medicine & Rehabilitation) Physician
3209
MA
225100000X
Physical Therapist
Primary
26548
MA
Other
Enumeration date
09/22/2017
Last updated
11/10/2022
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