Provider Demographics
NPI:1093598484
Name:FULLER, JORDAN S (PHD)
Entity type:Individual
Prefix:DR
First Name:JORDAN
Middle Name:S
Last Name:FULLER
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17751 WEXFORD ST
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4629
Mailing Address - Country:US
Mailing Address - Phone:913-449-6522
Mailing Address - Fax:
Practice Address - Street 1:3011 BALTIMORE AVE
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64108-3403
Practice Address - Country:US
Practice Address - Phone:159-874-6836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301019267103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist