Provider Demographics
NPI:1225394596
Name:DONOVAN, JACQUELINE KATHRYN (DPM)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:KATHRYN
Last Name:DONOVAN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23175 COMMERCE PARK STE C
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5806
Mailing Address - Country:US
Mailing Address - Phone:216-299-6774
Mailing Address - Fax:440-583-3097
Practice Address - Street 1:23175 COMMERCE PARK STE C
Practice Address - Street 2:
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5806
Practice Address - Country:US
Practice Address - Phone:216-299-6774
Practice Address - Fax:440-583-3097
Is Sole Proprietor?:No
Enumeration Date:2012-04-11
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
OH36003737213ES0103X
OH36.003737213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0424757Medicaid