Healthcare Provider Details

I. General information

NPI: 1164921219
Provider Name (Legal Business Name): JESSE ANDREW FULLEN BCBA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2018
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18685 MAIN ST STE 101-459
HUNTINGTON BEACH CA
92648-1723
US

IV. Provider business mailing address

18685 MAIN ST STE 101-459
HUNTINGTON BEACH CA
92648-1723
US

V. Phone/Fax

Practice location:
  • Phone: 714-697-1907
  • Fax: 844-904-0895
Mailing address:
  • Phone: 714-697-1907
  • Fax: 844-904-0895

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-19-36265
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: