Provider Demographics
NPI:1518612332
Name:CORONADO, JEAN CARLOS (BA)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:CARLOS
Last Name:CORONADO
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 CAHILL DR
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-3971
Mailing Address - Country:US
Mailing Address - Phone:201-741-6928
Mailing Address - Fax:
Practice Address - Street 1:508 NEW HOPE RD STE 208
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2271
Practice Address - Country:US
Practice Address - Phone:304-887-4799
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-21
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)