Provider Demographics
NPI:1578518700
Name:DONNELLY, JEAN MARIE (PHD)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:MARIE
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:535 WEST 110TH STREET
Mailing Address - Street 2:SUITE 1J
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-2066
Mailing Address - Country:US
Mailing Address - Phone:212-579-9288
Mailing Address - Fax:212-579-9288
Practice Address - Street 1:535 W 110TH ST
Practice Address - Street 2:SUITE 1J
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-2086
Practice Address - Country:US
Practice Address - Phone:212-579-9288
Practice Address - Fax:212-579-9288
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY013444-1103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical