Provider Demographics
NPI:1477313815
Name:FULLER, JAKE E (LLPC)
Entity type:Individual
Prefix:MR
First Name:JAKE
Middle Name:E
Last Name:FULLER
Suffix:
Gender:M
Credentials:LLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 W SHAWNEE ST
Mailing Address - Street 2:
Mailing Address - City:TECUMSEH
Mailing Address - State:MI
Mailing Address - Zip Code:49286-1566
Mailing Address - Country:US
Mailing Address - Phone:312-718-4221
Mailing Address - Fax:
Practice Address - Street 1:142 E MAUMEE ST STE 3
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-2735
Practice Address - Country:US
Practice Address - Phone:312-718-4221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-21
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health