Provider Demographics
NPI:1154825735
Name:FULLER, JESSICA LEANNE (MA, BCBA, LBA-NY)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEANNE
Last Name:FULLER
Suffix:
Gender:F
Credentials:MA, BCBA, LBA-NY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 W 95TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-6604
Mailing Address - Country:US
Mailing Address - Phone:646-480-5756
Mailing Address - Fax:
Practice Address - Street 1:128 W 95TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-6604
Practice Address - Country:US
Practice Address - Phone:646-480-5756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001399103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst