Provider Demographics
NPI:1366638108
Name:FULLILOVE, JOAN ELLEN (LCSW,ACSW)
Entity Type:Individual
Prefix:
First Name:JOAN
Middle Name:ELLEN
Last Name:FULLILOVE
Suffix:
Gender:F
Credentials:LCSW,ACSW
Other - Prefix:
Other - First Name:JOAN
Other - Middle Name:M
Other - Last Name:FULLILOVE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW,ACSW
Mailing Address - Street 1:1907 JOHNSON ST
Mailing Address - Street 2:
Mailing Address - City:JENNINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70546
Mailing Address - Country:US
Mailing Address - Phone:337-824-1000
Mailing Address - Fax:337-824-4947
Practice Address - Street 1:1907 JOHNSON ST
Practice Address - Street 2:
Practice Address - City:JENNINGS
Practice Address - State:LA
Practice Address - Zip Code:70546-3627
Practice Address - Country:US
Practice Address - Phone:337-824-1000
Practice Address - Fax:337-824-4947
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-14
Last Update Date:2007-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA38361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical