Basic Information
| Provider Information | |||||||||
| NPI: | 1033636220 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TONDREAU | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 419885 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022419885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 1942944050 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1424 S MAIN ST STE 3 | ||||||||
| Address2: | |||||||||
| City: | ADRIAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492214309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173121710 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-21-49559 | CO | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | 7401001736 | MI | Y | Behavioral Health & Social Service Providers | Behavioral Analyst | 156F00000X | N | Eye and Vision Services Providers | Technician/Technologist |
No ID Information.