Provider Demographics
NPI:1700328432
Name:CONNOLLY, JEREMY PAUL
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:PAUL
Last Name:CONNOLLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 NAPOLEON AVE APT E
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70115-2800
Mailing Address - Country:US
Mailing Address - Phone:504-598-6402
Mailing Address - Fax:
Practice Address - Street 1:200 S BROAD ST
Practice Address - Street 2:SUITE 7
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70119-6447
Practice Address - Country:US
Practice Address - Phone:504-309-9991
Practice Address - Fax:504-309-9930
Is Sole Proprietor?:No
Enumeration Date:2016-11-11
Last Update Date:2016-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation