Provider Demographics
NPI:1659405629
Name:FULTZ, JILL M (MS, LLP)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:M
Last Name:FULTZ
Suffix:
Gender:F
Credentials:MS, LLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42658 SOMERSET DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-3023
Mailing Address - Country:US
Mailing Address - Phone:734-981-4285
Mailing Address - Fax:
Practice Address - Street 1:43825 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48188-2551
Practice Address - Country:US
Practice Address - Phone:734-397-3088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301012299103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical