Basic Information
Provider Information | |||||||||
NPI: | 1134737240 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FONT-LLORENS | ||||||||
FirstName: | JEANDRILIE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 147 NORMAN ST | ||||||||
Address2: |   | ||||||||
City: | WEST SPRINGFIELD | ||||||||
State: | MA | ||||||||
PostalCode: | 010895003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4132966181 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 440 MCCLELLAN HWY STE 105B | ||||||||
Address2: |   | ||||||||
City: | BOSTON | ||||||||
State: | MA | ||||||||
PostalCode: | 021281101 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5082326670 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/15/2020 | ||||||||
LastUpdateDate: | 07/15/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/15/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X |   |   | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
ID | Type | State | Issuer | Description | 1134107113 | 05 | MA |   | MEDICAID | 1134107113 | 01 | MA | Y10086 | OTHER |