Provider Demographics
NPI:1497230676
Name:JEAN GILLES, ANTOINE LEISSA
Entity Type:Individual
Prefix:
First Name:ANTOINE
Middle Name:LEISSA
Last Name:JEAN GILLES
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 1:2054 NOSTRAND AVE APT 2D
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210-2525
Mailing Address - Country:US
Mailing Address - Phone:347-798-7446
Mailing Address - Fax:
Practice Address - Street 1:2054 NOSTRAND
Practice Address - Street 2:D2
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210
Practice Address - Country:US
Practice Address - Phone:347-798-7446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-03
Last Update Date:2018-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst