Provider Demographics
NPI:1396298782
Name:FORTIN, JEAN-LUC
Entity type:Individual
Prefix:
First Name:JEAN-LUC
Middle Name:
Last Name:FORTIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 ARIZONA AVE
Mailing Address - Street 2:STE 1500
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12903-4908
Mailing Address - Country:US
Mailing Address - Phone:518-565-4060
Mailing Address - Fax:518-566-0168
Practice Address - Street 1:130 ARIZONA AVE
Practice Address - Street 2:STE 1500
Practice Address - City:PLATTSBURGH
Practice Address - State:NY
Practice Address - Zip Code:12903-4908
Practice Address - Country:US
Practice Address - Phone:518-565-4060
Practice Address - Fax:518-566-0168
Is Sole Proprietor?:No
Enumeration Date:2016-08-02
Last Update Date:2016-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health