Provider Demographics
NPI:1801695200
Name:FULLER, JELANI (LPC-A)
Entity type:Individual
Prefix:
First Name:JELANI
Middle Name:
Last Name:FULLER
Suffix:
Gender:M
Credentials:LPC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14331 SONORA BND
Mailing Address - Street 2:
Mailing Address - City:HELOTES
Mailing Address - State:TX
Mailing Address - Zip Code:78023-4494
Mailing Address - Country:US
Mailing Address - Phone:210-884-4096
Mailing Address - Fax:
Practice Address - Street 1:14331 SONORA BND
Practice Address - Street 2:
Practice Address - City:HELOTES
Practice Address - State:TX
Practice Address - Zip Code:78023-4494
Practice Address - Country:US
Practice Address - Phone:210-884-4096
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-10
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX94633101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health