Provider Demographics
NPI:1528346137
Name:FULTON, JILL THERESE (LISW-S, LICDC)
Entity type:Individual
Prefix:MS
First Name:JILL
Middle Name:THERESE
Last Name:FULTON
Suffix:
Gender:F
Credentials:LISW-S, LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8227 BRECKSVILLE RD
Mailing Address - Street 2:SUITE104
Mailing Address - City:BRECKSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44141-1370
Mailing Address - Country:US
Mailing Address - Phone:440-526-0468
Mailing Address - Fax:440-526-0454
Practice Address - Street 1:8227 BRECKSVILLE RD
Practice Address - Street 2:SUITE104
Practice Address - City:BRECKSVILLE
Practice Address - State:OH
Practice Address - Zip Code:44141-1370
Practice Address - Country:US
Practice Address - Phone:440-526-0468
Practice Address - Fax:440-526-0454
Is Sole Proprietor?:No
Enumeration Date:2011-07-31
Last Update Date:2012-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI-0002356104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker