Healthcare Provider Details

I. General information

NPI: 1821808296
Provider Name (Legal Business Name): FFC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2025
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29532 SOUTHFIELD RD STE 115
SOUTHFIELD MI
48076-2023
US

IV. Provider business mailing address

29532 SOUTHFIELD RD STE 115
SOUTHFIELD MI
48076-2023
US

V. Phone/Fax

Practice location:
  • Phone: 734-215-5404
  • Fax: 570-989-5073
Mailing address:
  • Phone: 734-215-5404
  • Fax: 570-989-5073

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. JAKE EDWARD FULLER
Title or Position: MANAGING MEMBER
Credential: LPC
Phone: 312-718-4221