Provider Demographics
NPI:1023303971
Name:BISSONNETTE, JEFFREY W (CGC)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:W
Last Name:BISSONNETTE
Suffix:
Gender:M
Credentials:CGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:481 EDWARD H ROSS DR
Mailing Address - Street 2:
Mailing Address - City:ELMWOOD PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07407-3118
Mailing Address - Country:US
Mailing Address - Phone:616-307-7022
Mailing Address - Fax:
Practice Address - Street 1:481 EDWARD H ROSS DR
Practice Address - Street 2:
Practice Address - City:ELMWOOD PARK
Practice Address - State:NJ
Practice Address - Zip Code:07407-3118
Practice Address - Country:US
Practice Address - Phone:616-307-7022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI15433170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS