Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1041C0700X | Clinical Social Worker | 4005 | HI |
NPI | 1003209289 |
---|---|
Provider Name | Jessica Fuller |
First Address | El Paso, TX 79920-5002 |
Second Address | El Paso, TX 79920-5002 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/03/2015 |
Last Update Date | 11/03/2015 |