Provider Demographics
NPI:1144018847
Name:SMITH-FULIA, JESSE (LCSW)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:SMITH-FULIA
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 RED BUD LN
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:IL
Mailing Address - Zip Code:62995-1792
Mailing Address - Country:US
Mailing Address - Phone:618-658-3079
Mailing Address - Fax:
Practice Address - Street 1:300 RED BUD LN
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:IL
Practice Address - Zip Code:62995-1792
Practice Address - Country:US
Practice Address - Phone:618-658-3079
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-30
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490292001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical