Provider Demographics
NPI:1831398874
Name:FULLEN, ALLISON ELIZABETH (LCSW)
Entity type:Individual
Prefix:MS
First Name:ALLISON
Middle Name:ELIZABETH
Last Name:FULLEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2411 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72076-4211
Mailing Address - Country:US
Mailing Address - Phone:501-982-5402
Mailing Address - Fax:501-982-5404
Practice Address - Street 1:2411 W MAIN ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-4211
Practice Address - Country:US
Practice Address - Phone:501-982-5402
Practice Address - Fax:501-982-5404
Is Sole Proprietor?:No
Enumeration Date:2007-07-11
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 390200000X
AR2221M104100000X
AR2558-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR150200726Medicaid