Healthcare Provider Details

I. General information

NPI: 1386305928
Provider Name (Legal Business Name): JENNIFER ANN FULLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2022
Last Update Date: 06/29/2023
Certification Date: 06/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PINE AVE
LONG BEACH CA
90813-3124
US

IV. Provider business mailing address

375 TERMINO AVE APT I
LONG BEACH CA
90814-2870
US

V. Phone/Fax

Practice location:
  • Phone: 562-595-1159
  • Fax:
Mailing address:
  • Phone: 424-340-4522
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number112365
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number112365
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: