Provider Demographics
NPI:1760498604
Name:PONTILLO, JENNIFER A (LMHC, LCMHC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:A
Last Name:PONTILLO
Suffix:
Gender:F
Credentials:LMHC, LCMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 HIGHLAND AVE # 1161
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02494-3025
Mailing Address - Country:US
Mailing Address - Phone:781-423-1856
Mailing Address - Fax:
Practice Address - Street 1:3285 S COUNTY TRL STE 2B
Practice Address - Street 2:
Practice Address - City:EAST GREENWICH
Practice Address - State:RI
Practice Address - Zip Code:02818-1469
Practice Address - Country:US
Practice Address - Phone:781-423-1856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2023-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5448101YM0800X
RIMHC00267101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
1021740OtherNHP/BEACON-GROUP NUMBER
12398397OtherMULTIPLAN
RI413171OtherBLUE CHIP
RIJM5906Medicaid
RI1073750OtherNEIGHBORHOOD OF RI
83125900OtherMAGELLAN
31117-1OtherBLUE CROSS/SHIELD
RI62-38609OtherUNITED