Provider Demographics
NPI:1134522253
Name:JESSICA LANDRY FULTZ, LCSW, LLC
Entity type:Organization
Organization Name:JESSICA LANDRY FULTZ, LCSW, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LCSW
Authorized Official - Prefix:MRS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:LANDRY
Authorized Official - Last Name:FULTZ
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:318-305-9210
Mailing Address - Street 1:PO BOX 65
Mailing Address - Street 2:
Mailing Address - City:HESSMER
Mailing Address - State:LA
Mailing Address - Zip Code:71341-0065
Mailing Address - Country:US
Mailing Address - Phone:318-305-9210
Mailing Address - Fax:
Practice Address - Street 1:221 N MONROE ST
Practice Address - Street 2:SUITE B
Practice Address - City:MARKSVILLE
Practice Address - State:LA
Practice Address - Zip Code:71351-2311
Practice Address - Country:US
Practice Address - Phone:318-305-9210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-02
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11307251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health