Provider Demographics
NPI:1770804304
Name:STANELUN, JESSICA ANNE
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:ANNE
Last Name:STANELUN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 EDDY STREET
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905
Mailing Address - Country:US
Mailing Address - Phone:401-533-9100
Mailing Address - Fax:
Practice Address - Street 1:1000 EDDY STREET
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905
Practice Address - Country:US
Practice Address - Phone:401-533-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-17
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI0614OtherNHP RI
RIES01788Medicaid
RISB870OtherBC RI