Provider Demographics
NPI:1235847302
Name:FUSSELL, JENNIFER KELSIE (APC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:KELSIE
Last Name:FUSSELL
Suffix:
Gender:F
Credentials:APC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:HINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31313-2727
Mailing Address - Country:US
Mailing Address - Phone:912-876-4010
Mailing Address - Fax:
Practice Address - Street 1:101 E MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-2727
Practice Address - Country:US
Practice Address - Phone:912-876-4010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-08
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAPC800564101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health