Provider Demographics
NPI:1508415472
Name:FONSECA, JILLIAN MARIE (MS CCC-SLP)
Entity Type:Individual
Prefix:MISS
First Name:JILLIAN
Middle Name:MARIE
Last Name:FONSECA
Suffix:
Gender:F
Credentials:MS CCC-SLP
Other - Prefix:
Other - First Name:JILLIAN
Other - Middle Name:MARIE
Other - Last Name:THELEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:SLP
Mailing Address - Street 1:18 CRESTWOOD LN
Mailing Address - Street 2:
Mailing Address - City:CLARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07066-2640
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:227 EAST 41ST STREET
Practice Address - Street 2:8TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-1001
Practice Address - Country:US
Practice Address - Phone:212-273-6100
Practice Address - Fax:212-273-6427
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-04
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028995235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist