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General NPI Number Information
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NPI Number | 1477313815
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Entity Type | Individual
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Provider Name | JAKE E FULLER LLPC
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Gender | Male
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Dates
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Enumeration Date | 03/21/2024
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Last Update Date | 03/28/2024
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Provider Practice Location Address
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Address Line | 142 E MAUMEE ST STE 3
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City | ADRIAN
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State | MI
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Zip | 49221-2735
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Country | US
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Telephone | 312-718-4221
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Fax |
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Provider Business Mailing Address
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Address Line | 112 W SHAWNEE ST
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City | TECUMSEH
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State | MI
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Zip | 49286-1566
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Country | US
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Telephone | 312-718-4221
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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 | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number |
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License Number State |
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