Jordan Louis Fuller, PT, DPT, LAT, ATC

Primary specialty

Physical TherapistTaxonomy code 225100000X

License

26548 Issued in MA

Practice address

840 Winter St
Waltham, MA 02451-1433

Phone

(781) 487-9944

NPI assigned

Sep 22, 2017

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Enrolled in MA

Enrollment records 1

Specialty

Physical Therapist in Private Practice

Education

Other, 2022

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

Pro Sports Therapy IncGroup PAC ID 6901708544, 13 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

State licenses

Practice roles

Locations

Interoperability endpoints

• FHIR API: https://api.platform.athenahealth.com/1148/brand/1/csg/1/fhir/r4

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Pro Sports Therapy, Inc.

  • Physical Therapist
  • Waltham, MA
  • NPI 1780661090
  Medicare reassignment Care Compare group NPD

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1506038400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1668038400000",
    "number": "1992214803",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "50 OCEAN AVE APT 513A",
            "city": "REVERE",
            "state": "MA",
            "postal_code": "021513897",
            "telephone_number": "916-337-4524"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "840 WINTER ST",
            "city": "WALTHAM",
            "state": "MA",
            "postal_code": "024511433",
            "telephone_number": "781-487-9944"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "50 Ocean Ave Apt 513A",
            "address_purpose": "LOCATION",
            "city": "Revere",
            "state": "MA",
            "postal_code": "021513897",
            "country_code": "US",
            "telephone_number": "916-337-4524",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "FULLER",
        "first_name": "JORDAN",
        "middle_name": "LOUIS",
        "credential": "PT, DPT,  LAT, ATC",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2017-09-22",
        "last_updated": "2022-11-10",
        "certification_date": "2022-11-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "2081S0010X",
            "taxonomy_group": "",
            "desc": "Physical Medicine & Rehabilitation, Sports Medicine",
            "state": "MA",
            "license": "3209",
            "primary": false
        },
        {
            "code": "225100000X",
            "taxonomy_group": "",
            "desc": "Physical Therapist",
            "state": "MA",
            "license": "26548",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Annie F Friedman, LICSW
• Kimberly Ann Friend
• Zoie Gita Friend
• Front Range Kidney Care PLLC
• Thomas A Fry, MD
• Ridgely Plater Fuller
• Brittany Fung-Santos, DPT
• Muhammad Furqan, RPH
• Robert D Fusunyan, MD
• Gabriela Gabor Kertznus

• Physical Therapist in Waltham, MA
• Providers in Waltham, MA by specialty
• Physical Therapist in Massachusetts

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 10, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.