Healthcare Provider Details

I. General information

NPI: 1144917501
Provider Name (Legal Business Name): JACQUELINE L FULLER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2023
Last Update Date: 04/18/2023
Certification Date: 04/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

821 N EUTAW ST STE 201
BALTIMORE MD
21201-6301
US

IV. Provider business mailing address

27 TIMBER GROVE RD
OWINGS MILLS MD
21117-1820
US

V. Phone/Fax

Practice location:
  • Phone: 410-225-9185
  • Fax: 410-225-7964
Mailing address:
  • Phone: 443-965-8726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberADT2363
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: