Provider Demographics
NPI:1558510909
Name:JERUSSI, THERESA DONOHUE (MS, PA-C)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:DONOHUE
Last Name:JERUSSI
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:B
Other - Last Name:DONOHUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10 CENTER DRIVE MSC 1202
Mailing Address - Street 2:BUILDING 10, CRC RM 3-5272
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20892-0001
Mailing Address - Country:US
Mailing Address - Phone:301-594-8003
Mailing Address - Fax:301-480-0195
Practice Address - Street 1:10 CENTER DRIVE MSC 1202
Practice Address - Street 2:BUILDING 10, CRC RM 3-5272
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20892-0001
Practice Address - Country:US
Practice Address - Phone:301-594-8003
Practice Address - Fax:301-480-0195
Is Sole Proprietor?:No
Enumeration Date:2008-09-10
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002298363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant