1992182372 NPI number — JACQUELINE A RONDEAU PSYD

Table of content: (NPI 1992182372)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1992182372 NPI number — JACQUELINE A RONDEAU PSYD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JACQUELINE A RONDEAU PSYD
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1992182372
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/05/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
375 BELLEVILLE AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLOOMFIELD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07003-2634
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
973-743-4555
Provider Business Mailing Address Fax Number:
973-743-4055

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
70 PARK ST
Provider Second Line Business Practice Location Address:
SUITE 207
Provider Business Practice Location Address City Name:
MONTCLAIR
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07042-5907
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
973-743-4555
Provider Business Practice Location Address Fax Number:
973-743-4055
Provider Enumeration Date:
05/05/2015

Additional Information

Authorized Official

Authorized Official Last Name:
RONDEAU
Authorized Official First Name:
JACQUELINE
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
CLINICAL DIRECTOR
Authorized Official Telephone Number:
973-743-4555

Provider Taxonomy Codes

  • Taxonomy code: 103G00000X , with the licence number:  35SI00390000 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TC0700X , with the licence number: 35SI00390000 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 0051560 , issued by the state of ( NJ ) . This identifiers is of the category "MEDICAID".




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