Provider Demographics
NPI:1538637095
Name:FULLER, JENNIFER (LMHP-R)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:LMHP-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21335 SIGNAL HILL PLZ STE 270
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:VA
Mailing Address - Zip Code:20164-5567
Mailing Address - Country:US
Mailing Address - Phone:703-832-4591
Mailing Address - Fax:
Practice Address - Street 1:21335 SIGNAL HILL PLZ STE 270
Practice Address - Street 2:
Practice Address - City:STERLING
Practice Address - State:VA
Practice Address - Zip Code:20164-5567
Practice Address - Country:US
Practice Address - Phone:703-832-4591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-02
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
0730000384106H00000X
VA0730000384106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist