Provider Demographics
NPI:1366507972
Name:FONTANELLA, JILL ELIZABETH (LCSW, LADC)
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:ELIZABETH
Last Name:FONTANELLA
Suffix:
Gender:F
Credentials:LCSW, LADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 SHULER LN
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:CT
Mailing Address - Zip Code:06422-3012
Mailing Address - Country:US
Mailing Address - Phone:203-213-9078
Mailing Address - Fax:860-349-0324
Practice Address - Street 1:79 MILL ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-4468
Practice Address - Country:US
Practice Address - Phone:203-213-9078
Practice Address - Fax:860-349-0324
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-26
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0043821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical