Provider Demographics
NPI:1861784571
Name:FULLER, JENNIFER D (LPC, CAC II)
Entity type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:D
Last Name:FULLER
Suffix:
Gender:F
Credentials:LPC, CAC II
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 STEIN ST
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-1850
Mailing Address - Country:US
Mailing Address - Phone:303-827-4973
Mailing Address - Fax:
Practice Address - Street 1:304 W BASELINE RD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-1719
Practice Address - Country:US
Practice Address - Phone:303-827-4973
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-12
Last Update Date:2016-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO7203101YA0400X
CO5780101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)