Healthcare Provider Details

I. General information

NPI: 1639676729
Provider Name (Legal Business Name): JEANNETTE BALBONI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2018
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N SWALLOW TAIL DR
PORT ORANGE FL
32129-6102
US

IV. Provider business mailing address

6 WHITEHALL CT
FLAGLER BEACH FL
32136-4906
US

V. Phone/Fax

Practice location:
  • Phone: 413-896-6263
  • Fax:
Mailing address:
  • Phone: 413-896-6263
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCPC03094
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMH25264
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: