Provider Demographics
NPI:1245787464
Name:FULLER, JESSICA LIZETH (BS, BCABA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LIZETH
Last Name:FULLER
Suffix:
Gender:F
Credentials:BS, BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1904 S MACDILL AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-5903
Mailing Address - Country:US
Mailing Address - Phone:813-250-0482
Mailing Address - Fax:415-480-2496
Practice Address - Street 1:1904 S MACDILL AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-5903
Practice Address - Country:US
Practice Address - Phone:813-250-0482
Practice Address - Fax:415-480-2496
Is Sole Proprietor?:No
Enumeration Date:2016-09-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst