Provider Demographics
NPI:1558557371
Name:CONNELLY, JON (JON CONNELLY)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:
Last Name:CONNELLY
Suffix:
Gender:M
Credentials:JON CONNELLY
Other - Prefix:DR
Other - First Name:JON
Other - Middle Name:
Other - Last Name:CONNELLY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:JON CONNELLY
Mailing Address - Street 1:4286 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-5315
Mailing Address - Country:US
Mailing Address - Phone:561-741-4181
Mailing Address - Fax:
Practice Address - Street 1:4286 W MAIN ST
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-5315
Practice Address - Country:US
Practice Address - Phone:561-741-4181
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-16
Last Update Date:2007-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW23271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical