Provider Demographics
NPI:1609802701
Name:MACDONALD, JENNIFER MASSIMO (PT)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MASSIMO
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:MASSIMO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:500 CHASE PKWY
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-3346
Mailing Address - Country:US
Mailing Address - Phone:203-754-2266
Mailing Address - Fax:203-591-8680
Practice Address - Street 1:500 CHASE PKWY
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-3346
Practice Address - Country:US
Practice Address - Phone:203-754-2266
Practice Address - Fax:203-591-8680
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT007028225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT650000682Medicare ID - Type Unspecified