Provider Demographics
NPI:1417457623
Name:FULKERSON, JEFFREY RAY (M ED, MS, LAC, LPC)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:RAY
Last Name:FULKERSON
Suffix:
Gender:M
Credentials:M ED, MS, LAC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3920 S RURAL RD STE 112
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-5500
Mailing Address - Country:US
Mailing Address - Phone:480-428-2944
Mailing Address - Fax:480-680-5361
Practice Address - Street 1:3920 S RURAL RD STE 112
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-5500
Practice Address - Country:US
Practice Address - Phone:480-428-2944
Practice Address - Fax:480-680-5361
Is Sole Proprietor?:No
Enumeration Date:2018-02-14
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-21211101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional