MEDICARE: MRS. KAREN JEAN FULTON MACP, LMHC, CEAP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor	MH0002651	FL
2	101YM0800X	Mental Health Counselor	MH0002651	FL
3	101YP1600X	Pastoral Counselor	MH2651	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2651	OTHER	FL	LIC MENTAL HEALTH COUNSEL

General Provider Information

NPI Number	:	1356424956
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KAREN JEAN FULTON MACP, LMHC, CEAP

Provider Business Mailing Address
First Line	:	10175 FORTUNE PKWY
Second Line	:	UNIT 504
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-6746
Country	:	US
Telephone Number	:	904-363-6999
Fax Number	:	904-363-6996

Provider Business Practice Location Address
First Line	:	10175 FORTUNE PKWY
Second Line	:	UNIT 504
City	:	JACKSONVILLE
State	:	FL
Zip	:	32256-6746
Country	:	US
Telephone Number	:	904-363-6999
Fax Number	:	904-363-6996

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/24/2006
Last Update Date	:	03/09/2012

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