Provider Demographics
NPI:1386305928
Name:FULLER, JENNIFER ANN
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:FULLER
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 1:375 TERMINO AVE APT I
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90814-2870
Mailing Address - Country:US
Mailing Address - Phone:424-340-4522
Mailing Address - Fax:
Practice Address - Street 1:1301 PINE AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90813-3124
Practice Address - Country:US
Practice Address - Phone:562-595-1159
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-05
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1123651041C0700X, 101YM0800X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner