Provider Demographics
NPI:1376303610
Name:MENVILLE, JESSE ELLEN (BA)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:ELLEN
Last Name:MENVILLE
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 E GEORGE ST APT 2
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-3909
Mailing Address - Country:US
Mailing Address - Phone:201-739-4339
Mailing Address - Fax:
Practice Address - Street 1:2 DUDLEY ST STE 180
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-3248
Practice Address - Country:US
Practice Address - Phone:201-739-4339
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program