Provider Demographics
NPI:1043777576
Name:FULLER, JESSICA (PLMHP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:PLMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7929 W CENTER RD
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68124-3104
Mailing Address - Country:US
Mailing Address - Phone:877-518-1070
Mailing Address - Fax:402-591-5075
Practice Address - Street 1:11515 S 39TH ST
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:NE
Practice Address - Zip Code:68123-5200
Practice Address - Country:US
Practice Address - Phone:402-292-9105
Practice Address - Fax:402-292-0342
Is Sole Proprietor?:No
Enumeration Date:2019-02-20
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE11706101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health