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General NPI Number Information
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NPI Number | 1306223326
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Entity Type | Individual
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Provider Name | JENAH NUGENT-FULLAM
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Gender | Female
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Dates
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Enumeration Date | 04/28/2015
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Last Update Date | 04/28/2015
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Provider Practice Location Address
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Address Line | 5034 NEW FOREST ST APT 8309
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City | SAN ANTONIO
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State | TX
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Zip | 78229-5468
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Country | US
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Telephone | 210-281-5401
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Fax |
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Provider Business Mailing Address
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Address Line | 23519 ENCHANTED PATH
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City | SAN ANTONIO
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State | TX
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Zip | 78260-4337
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Country | US
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Telephone | 321-634-2327
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 235Z00000X
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Taxonomy Name | Speech-Language Pathologist
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License Number | 110529
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License Number State | TX
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