Provider Demographics
NPI:1780492918
Name:FONTAINE, JESSICA LYN (LPC-A)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYN
Last Name:FONTAINE
Suffix:
Gender:F
Credentials:LPC-A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 MIDFIELD DR APT 14
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06705-5939
Mailing Address - Country:US
Mailing Address - Phone:203-568-3413
Mailing Address - Fax:
Practice Address - Street 1:26 MIDFIELD DR APT 14
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06705-5939
Practice Address - Country:US
Practice Address - Phone:203-568-3413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-19
Last Update Date:2024-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7656101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor