Provider Demographics
NPI:1568696136
Name:FULLERTON, JENNIFER ANN (LICSW)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:FULLERTON
Suffix:
Gender:F
Credentials:LICSW
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 502
Mailing Address - Street 2:
Mailing Address - City:CAMPTON
Mailing Address - State:NH
Mailing Address - Zip Code:03223-0502
Mailing Address - Country:US
Mailing Address - Phone:603-616-6693
Mailing Address - Fax:
Practice Address - Street 1:85 MAIN ST STE 306
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03264-1500
Practice Address - Country:US
Practice Address - Phone:603-238-3149
Practice Address - Fax:603-238-9239
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH13301041C0700X
MELC117411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical