Provider Demographics
NPI:1649923582
Name:FULLWOOD, JACQUELINE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:FULLWOOD
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 1:2000 GLEN ECHO RD STE 101
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-2857
Mailing Address - Country:US
Mailing Address - Phone:615-457-8585
Mailing Address - Fax:615-457-8595
Practice Address - Street 1:2000 GLEN ECHO RD STE 101
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37215-2857
Practice Address - Country:US
Practice Address - Phone:615-457-8585
Practice Address - Fax:615-457-8595
Is Sole Proprietor?:No
Enumeration Date:2022-02-01
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor