Provider Demographics
NPI:1457893240
Name:FULLER, JANE
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1855 LAKELAND DR STE R305
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4954
Mailing Address - Country:US
Mailing Address - Phone:601-982-5376
Mailing Address - Fax:601-982-5377
Practice Address - Street 1:1855 LAKELAND DR STE R305
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4954
Practice Address - Country:US
Practice Address - Phone:601-982-5376
Practice Address - Fax:601-982-5377
Is Sole Proprietor?:No
Enumeration Date:2016-11-09
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS2124101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health