Provider Demographics
NPI:1225494883
Name:ILLERA, JHONATAN
Entity type:Individual
Prefix:
First Name:JHONATAN
Middle Name:
Last Name:ILLERA
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 1:19415D 65TH CRES
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365-4058
Mailing Address - Country:US
Mailing Address - Phone:646-244-9987
Mailing Address - Fax:
Practice Address - Street 1:19415D 65TH CRES
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365-4058
Practice Address - Country:US
Practice Address - Phone:646-244-9987
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-12
Last Update Date:2024-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009391101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health