Provider Demographics
NPI:1417456369
Name:CONNOLLY, JEANINE MARIE (MS, ATC/L)
Entity Type:Individual
Prefix:
First Name:JEANINE
Middle Name:MARIE
Last Name:CONNOLLY
Suffix:
Gender:F
Credentials:MS, ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 PROGRESSIVE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST BRIDGEWATER
Mailing Address - State:MA
Mailing Address - Zip Code:02379-1126
Mailing Address - Country:US
Mailing Address - Phone:508-243-5292
Mailing Address - Fax:
Practice Address - Street 1:295 OLD OAK ST
Practice Address - Street 2:
Practice Address - City:PEMBROKE
Practice Address - State:MA
Practice Address - Zip Code:02359-1955
Practice Address - Country:US
Practice Address - Phone:857-444-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-06
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA23722255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer