Healthcare Provider Details

I. General information

NPI: 1548527096
Provider Name (Legal Business Name): JEFFREY ALAN FULMER LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2012
Last Update Date: 01/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 COURT ST
LYNCHBURG VA
24504-1312
US

IV. Provider business mailing address

482 BEDFORD SPRINGS RD
LYNCHBURG VA
24502-5610
US

V. Phone/Fax

Practice location:
  • Phone: 434-847-8035
  • Fax: 434-485-8877
Mailing address:
  • Phone: 937-371-1120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0904008669
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: