Provider Demographics
NPI:1386510071
Name:FONTAINE, JEBADIAH
Entity type:Individual
Prefix:
First Name:JEBADIAH
Middle Name:
Last Name:FONTAINE
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:RI
Mailing Address - Zip Code:02885-3009
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:RI
Practice Address - Zip Code:02885-3009
Practice Address - Country:US
Practice Address - Phone:207-852-1175
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-11
Last Update Date:2025-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool