Provider Demographics
NPI:1326560384
Name:FULLER, JESSICA ASHTON (MSW, LCSW, LCAS,CCTP)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:ASHTON
Last Name:FULLER
Suffix:
Gender:F
Credentials:MSW, LCSW, LCAS,CCTP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 POLLOCK ST
Mailing Address - Street 2:
Mailing Address - City:POLLOCKSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28573-8812
Mailing Address - Country:US
Mailing Address - Phone:252-670-1344
Mailing Address - Fax:
Practice Address - Street 1:233 MIDDLE ST STE 105
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28560-2101
Practice Address - Country:US
Practice Address - Phone:252-228-9603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-12
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0126371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical