Provider Demographics
NPI:1285622217
Name:RONDEAU, JACQUELINE ANN (PSYD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:ANN
Last Name:RONDEAU
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8121
Mailing Address - Street 2:
Mailing Address - City:GLEN RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07028-8121
Mailing Address - Country:US
Mailing Address - Phone:973-743-4555
Mailing Address - Fax:973-743-4055
Practice Address - Street 1:28 VALLEY RD
Practice Address - Street 2:
Practice Address - City:MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07042-2709
Practice Address - Country:US
Practice Address - Phone:973-746-4555
Practice Address - Fax:973-783-4055
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ35SI00390000103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0051560Medicaid
NJ0051560Medicaid