Provider Demographics
NPI:1124538897
Name:BISONETTE, JILLIAN
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:
Last Name:BISONETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:588 OLD MARKET RD
Mailing Address - Street 2:
Mailing Address - City:POTSDAM
Mailing Address - State:NY
Mailing Address - Zip Code:13676-3248
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:70 EDGEWOOD RD
Practice Address - Street 2:
Practice Address - City:SARANAC LAKE
Practice Address - State:NY
Practice Address - Zip Code:12983-1537
Practice Address - Country:US
Practice Address - Phone:518-891-5535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-06
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator