Provider Demographics
NPI:1275913493
Name:MCDONALD, JEROME (BA)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3036 MATTHEWS AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-8600
Mailing Address - Country:US
Mailing Address - Phone:347-272-3746
Mailing Address - Fax:718-994-1361
Practice Address - Street 1:3036 MATTHEWS AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-8600
Practice Address - Country:US
Practice Address - Phone:347-272-3746
Practice Address - Fax:718-994-1361
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-03
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst