Provider Demographics
NPI:1871305573
Name:FULLER, JEFF (MSW, LSW)
Entity type:Individual
Prefix:
First Name:JEFF
Middle Name:
Last Name:FULLER
Suffix:
Gender:M
Credentials:MSW, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5110 CEDAR MILL LN
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-8664
Mailing Address - Country:US
Mailing Address - Phone:317-696-1626
Mailing Address - Fax:
Practice Address - Street 1:5110 CEDAR MILL LN
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8664
Practice Address - Country:US
Practice Address - Phone:317-696-1626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-21
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33011463A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health