Provider Demographics
NPI:1467949628
Name:FUCELLA, JONATHAN L (LCSW)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:L
Last Name:FUCELLA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-343-9180
Mailing Address - Fax:239-343-9188
Practice Address - Street 1:12550 NEW BRITTANY BLVD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907
Practice Address - Country:US
Practice Address - Phone:239-343-9180
Practice Address - Fax:239-343-9188
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-13
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW146621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL101937100Medicaid