Provider Demographics
NPI:1407007792
Name:FONTAINE, JESSICA (MS, BCBA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:MS, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 BARLOW RD
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23188-2227
Mailing Address - Country:US
Mailing Address - Phone:205-239-4448
Mailing Address - Fax:
Practice Address - Street 1:1317 JAMESTOWN RD
Practice Address - Street 2:SUITE 102-B
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185-3364
Practice Address - Country:US
Practice Address - Phone:205-239-4448
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-05
Last Update Date:2011-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-08-4204103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst