Provider Demographics
NPI:1487905980
Name:ADONTENG, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:ADONTENG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:93 LENO RD
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MA
Mailing Address - Zip Code:01521-2707
Mailing Address - Country:US
Mailing Address - Phone:774-452-9533
Mailing Address - Fax:
Practice Address - Street 1:468 MAIN STREET
Practice Address - Street 2:
Practice Address - City:STURBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:01518
Practice Address - Country:US
Practice Address - Phone:774-452-9533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-24
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X
MA11097101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM18684OtherBLUE CROSS BLUE SHEILD
MA1308785Medicaid
MA1306421Medicaid
MA22220002001OtherBLUE CROSS BLUE SHEILD
MAY10400Medicare PIN