Provider Demographics
NPI:1912069428
Name:FUSSELL, JUANITA J (EDD)
Entity type:Individual
Prefix:DR
First Name:JUANITA
Middle Name:J
Last Name:FUSSELL
Suffix:
Gender:F
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3115 FOWLER MONTGOMERY RD
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38506-6469
Mailing Address - Country:US
Mailing Address - Phone:931-526-8000
Mailing Address - Fax:931-526-8000
Practice Address - Street 1:805 N WILLOW AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-1751
Practice Address - Country:US
Practice Address - Phone:931-526-8000
Practice Address - Fax:931-526-8000
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP0000001338103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103919OtherCIGNA
TN3094270OtherBLUE CROSS BLUE SHIELD
TN103919OtherCIGNA