Provider Demographics
NPI:1417469628
Name:FULLWILEY, JOJUAN (BCBA)
Entity Type:Individual
Prefix:MS
First Name:JOJUAN
Middle Name:
Last Name:FULLWILEY
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3834 GINKGO LN APT 206
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38125-6538
Mailing Address - Country:US
Mailing Address - Phone:901-336-4225
Mailing Address - Fax:
Practice Address - Street 1:3834 GINKGO LN
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38125-6538
Practice Address - Country:US
Practice Address - Phone:901-336-4225
Practice Address - Fax:901-910-3399
Is Sole Proprietor?:No
Enumeration Date:2017-10-27
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1-18-33518103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst