1508415472 NPI number — MISS JILLIAN MARIE FONSECA M.S. CCC-SLP

Table of content: MISS JILLIAN MARIE FONSECA M.S. CCC-SLP (NPI 1508415472)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508415472 NPI number — MISS JILLIAN MARIE FONSECA M.S. CCC-SLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FONSECA
Provider First Name:
JILLIAN
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
M.S. CCC-SLP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
THELEN
Provider Other First Name:
JILLIAN
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
SLP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1508415472
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
18 CRESTWOOD LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLARK
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07066-2640
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
227 EAST 41ST STREET
Provider Second Line Business Practice Location Address:
8TH FLOOR
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10017-1001
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-273-6100
Provider Business Practice Location Address Fax Number:
212-273-6427
Provider Enumeration Date:
09/04/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  028995 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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