Provider Demographics
NPI:1720369838
Name:ANTILUS, JESSALYNNE MARIE (MA)
Entity Type:Individual
Prefix:MS
First Name:JESSALYNNE
Middle Name:MARIE
Last Name:ANTILUS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:JESSALYNNE
Other - Middle Name:MARIE
Other - Last Name:BERGIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 W PEARL ST
Mailing Address - Street 2:
Mailing Address - City:NASHUA
Mailing Address - State:NH
Mailing Address - Zip Code:03060-3343
Mailing Address - Country:US
Mailing Address - Phone:603-889-6147
Mailing Address - Fax:
Practice Address - Street 1:5 PINE STREET EXT
Practice Address - Street 2:
Practice Address - City:NASHUA
Practice Address - State:NH
Practice Address - Zip Code:03060-3248
Practice Address - Country:US
Practice Address - Phone:603-889-6147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-01
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health