Provider Demographics
NPI:1740989896
Name:JADED LOTUS ACADEMY
Entity type:Organization
Organization Name:JADED LOTUS ACADEMY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JOJUAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLWILEY
Authorized Official - Suffix:
Authorized Official - Credentials:BCBA
Authorized Official - Phone:901-498-0108
Mailing Address - Street 1:5115 COVINGTON WAY STE 5
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38134-5619
Mailing Address - Country:US
Mailing Address - Phone:901-498-0108
Mailing Address - Fax:901-910-3399
Practice Address - Street 1:5115 COVINGTON WAY STE 5
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38134-5619
Practice Address - Country:US
Practice Address - Phone:901-498-0108
Practice Address - Fax:901-910-3399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-02-27
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior AnalystGroup - Single Specialty