Provider Demographics
NPI:1134012974
Name:FULLER, CALEY JEAN
Entity type:Individual
Prefix:
First Name:CALEY
Middle Name:JEAN
Last Name:FULLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CALEY
Other - Middle Name:JEAN
Other - Last Name:FRERICHS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:694 N 240 E
Mailing Address - Street 2:
Mailing Address - City:SMITHFIELD
Mailing Address - State:UT
Mailing Address - Zip Code:84335-2525
Mailing Address - Country:US
Mailing Address - Phone:208-251-6131
Mailing Address - Fax:
Practice Address - Street 1:95 GOLF COURSE RD STE 105
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-5990
Practice Address - Country:US
Practice Address - Phone:435-915-6398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-30
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14222525-3904106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist