Provider Demographics
NPI:1962287672
Name:TAVAREZ, JONNELLE (LSW)
Entity type:Individual
Prefix:
First Name:JONNELLE
Middle Name:
Last Name:TAVAREZ
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:JONNELLE
Other - Middle Name:
Other - Last Name:RODRIGUEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LSW
Mailing Address - Street 1:408 HABITAT WAY
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32773-4340
Mailing Address - Country:US
Mailing Address - Phone:908-906-8400
Mailing Address - Fax:
Practice Address - Street 1:2083 KLOCKNER RD
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:NJ
Practice Address - Zip Code:08690-3415
Practice Address - Country:US
Practice Address - Phone:609-222-4902
Practice Address - Fax:640-888-7533
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06029000104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker