Provider Demographics
NPI:1164193421
Name:FULLER, JACK MCBRYDE
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:MCBRYDE
Last Name:FULLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7575 WATER FALL TRL
Mailing Address - Street 2:
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44022-3965
Mailing Address - Country:US
Mailing Address - Phone:216-296-1184
Mailing Address - Fax:
Practice Address - Street 1:33595 BAINBRIDGE RD STE 101
Practice Address - Street 2:
Practice Address - City:SOLON
Practice Address - State:OH
Practice Address - Zip Code:44139-2981
Practice Address - Country:US
Practice Address - Phone:800-642-4560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-25
Last Update Date:2021-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor