Healthcare Provider Details

I. General information

NPI: 1699077461
Provider Name (Legal Business Name): JANA CLAIRE FULMER MSC, CMHC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2010
Last Update Date: 11/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

447 BEARCAT DR
SALT LAKE CITY UT
84115-2519
US

IV. Provider business mailing address

200 PARKVIEW DR
PARK CITY UT
84098-5144
US

V. Phone/Fax

Practice location:
  • Phone: 801-355-2846
  • Fax: 801-359-3244
Mailing address:
  • Phone: 801-355-2846
  • Fax: 801-359-3244

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number6053262-6004
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6053262-6009
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: