Provider Demographics
NPI:1295883965
Name:MIGNEAULT, JEFFREY P (PHD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:P
Last Name:MIGNEAULT
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:347 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02909-1101
Mailing Address - Country:US
Mailing Address - Phone:401-270-9808
Mailing Address - Fax:401-270-9808
Practice Address - Street 1:347 BROADWAY
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02909-1101
Practice Address - Country:US
Practice Address - Phone:401-270-9808
Practice Address - Fax:401-270-9808
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2011-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS00585103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI689002659Medicare ID - Type Unspecified