Provider Demographics
NPI:1649687450
Name:FULTON, JUANA (LCSW)
Entity type:Individual
Prefix:MRS
First Name:JUANA
Middle Name:
Last Name:FULTON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MRS
Other - First Name:JUANA
Other - Middle Name:SILVA
Other - Last Name:FULTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:N/A
Mailing Address - Street 1:1250 MORENA BLVD.
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3815
Mailing Address - Country:US
Mailing Address - Phone:619-692-8750
Mailing Address - Fax:619-275-7343
Practice Address - Street 1:1250 MORENA BLVD.
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3815
Practice Address - Country:US
Practice Address - Phone:619-692-8750
Practice Address - Fax:619-275-7343
Is Sole Proprietor?:No
Enumeration Date:2014-07-14
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CAASW68292104100000X
CALCSW870621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker