Provider Demographics
NPI:1306223326
Name:NUGENT-FULLAM, JENAH
Entity Type:Individual
Prefix:
First Name:JENAH
Middle Name:
Last Name:NUGENT-FULLAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23519 ENCHANTED PATH
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78260-4337
Mailing Address - Country:US
Mailing Address - Phone:321-634-2327
Mailing Address - Fax:
Practice Address - Street 1:5034 NEW FOREST ST APT 8309
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-5468
Practice Address - Country:US
Practice Address - Phone:210-281-5401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-28
Last Update Date:2015-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110529235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist