Healthcare Provider Details

I. General information

NPI: 1992182372
Provider Name (Legal Business Name): JACQUELINE A RONDEAU PSYD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2015
Last Update Date: 05/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 PARK ST SUITE 207
MONTCLAIR NJ
07042-5907
US

IV. Provider business mailing address

375 BELLEVILLE AVE
BLOOMFIELD NJ
07003-2634
US

V. Phone/Fax

Practice location:
  • Phone: 973-743-4555
  • Fax: 973-743-4055
Mailing address:
  • Phone: 973-743-4555
  • Fax: 973-743-4055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number35SI00390000
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number35SI00390000
License Number StateNJ

VIII. Authorized Official

Name: DR. JACQUELINE ANN RONDEAU
Title or Position: CLINICAL DIRECTOR
Credential: PSYD
Phone: 973-743-4555