Provider Demographics
NPI:1992182372
Name:JACQUELINE A RONDEAU PSYD
Entity Type:Organization
Organization Name:JACQUELINE A RONDEAU PSYD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:RONDEAU
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:973-743-4555
Mailing Address - Street 1:375 BELLEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-2634
Mailing Address - Country:US
Mailing Address - Phone:973-743-4555
Mailing Address - Fax:973-743-4055
Practice Address - Street 1:70 PARK ST
Practice Address - Street 2:SUITE 207
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-5907
Practice Address - Country:US
Practice Address - Phone:973-743-4555
Practice Address - Fax:973-743-4055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-05
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00390000103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0051560Medicaid
049043Medicare UPIN