Provider Demographics
NPI:1801386230
Name:FULLER, JENNIFER (LPC, LAC, AADC, NCC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:LPC, LAC, AADC, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810A TEXAS AVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-4829
Mailing Address - Country:US
Mailing Address - Phone:844-433-2564
Mailing Address - Fax:
Practice Address - Street 1:810A TEXAS AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-4829
Practice Address - Country:US
Practice Address - Phone:844-433-2564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018009719101YP2500X
LA6149101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional