Provider Demographics
NPI:1083242788
Name:FOURNIER, ELEXUS JADE
Entity Type:Individual
Prefix:
First Name:ELEXUS
Middle Name:JADE
Last Name:FOURNIER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7177 CRIMSON RIDGE DR STE 110
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-6235
Mailing Address - Country:US
Mailing Address - Phone:779-771-6343
Mailing Address - Fax:
Practice Address - Street 1:7177 CRIMSON RIDGE DR STE 110
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-6235
Practice Address - Country:US
Practice Address - Phone:779-771-6343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-29
Last Update Date:2020-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician