Provider Demographics
NPI:1578156485
Name:MCDONALD, TEAGAN JAYNE
Entity Type:Individual
Prefix:
First Name:TEAGAN
Middle Name:JAYNE
Last Name:MCDONALD
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 1:11043 COYLE RD
Mailing Address - Street 2:
Mailing Address - City:QUILCENE
Mailing Address - State:WA
Mailing Address - Zip Code:98376-8659
Mailing Address - Country:US
Mailing Address - Phone:208-270-1149
Mailing Address - Fax:
Practice Address - Street 1:231 W PATISON ST
Practice Address - Street 2:
Practice Address - City:PORT HADLOCK
Practice Address - State:WA
Practice Address - Zip Code:98339-9751
Practice Address - Country:US
Practice Address - Phone:360-385-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-11
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMASS.MA.61140528225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist