Provider Demographics
NPI:1962035907
Name:LAFONTAINE, JESSICA MARIE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:LAFONTAINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:MIKULAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:630 S WICKHAM RD STE 107
Mailing Address - Street 2:
Mailing Address - City:WEST MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32904-1429
Mailing Address - Country:US
Mailing Address - Phone:321-608-0604
Mailing Address - Fax:
Practice Address - Street 1:630 S WICKHAM RD STE 107
Practice Address - Street 2:
Practice Address - City:WEST MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32904-1429
Practice Address - Country:US
Practice Address - Phone:321-608-0604
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-18
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical