Provider Demographics
NPI:1558168302
Name:FONICELLO, JESSICA (CBE, CLC, CD, PRA)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:FONICELLO
Suffix:
Gender:
Credentials:CBE, CLC, CD, PRA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 LITTLE MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437-1617
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2120 LITTLE MEADOW RD
Practice Address - Street 2:
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437-1617
Practice Address - Country:US
Practice Address - Phone:203-415-2388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-28
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374J00000XNursing Service Related ProvidersDoulaGroup - Multi-Specialty
No172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty