Provider Demographics
NPI:1114408275
Name:DONAHUE, JACQUELINE GAIL
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:GAIL
Last Name:DONAHUE
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 1:235 N PEARL ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-1794
Mailing Address - Country:US
Mailing Address - Phone:508-427-3000
Mailing Address - Fax:
Practice Address - Street 1:235 N PEARL ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-1794
Practice Address - Country:US
Practice Address - Phone:508-427-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10264781041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA$$$$$$$$$Medicaid