Provider Demographics
NPI:1225782436
Name:FULLER, SHERRIES (RBT)
Entity Type:Individual
Prefix:
First Name:SHERRIES
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:72 FOXWORTH DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-6703
Mailing Address - Country:US
Mailing Address - Phone:731-212-7704
Mailing Address - Fax:
Practice Address - Street 1:1119 OLD HUMBOLDT RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-1752
Practice Address - Country:US
Practice Address - Phone:901-443-9146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician