Provider Demographics
NPI:1699810119
Name:CONDON, JEAN M (DT)
Entity Type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:M
Last Name:CONDON
Suffix:
Gender:F
Credentials:DT
Other - Prefix:
Other - First Name:JEAN
Other - Middle Name:
Other - Last Name:CROTCHETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:RR 5 BOX 126H
Mailing Address - Street 2:
Mailing Address - City:GRUNDY
Mailing Address - State:VA
Mailing Address - Zip Code:24614-9508
Mailing Address - Country:US
Mailing Address - Phone:276-935-2651
Mailing Address - Fax:
Practice Address - Street 1:RR 5 BOX 126H
Practice Address - Street 2:
Practice Address - City:GRUNDY
Practice Address - State:VA
Practice Address - Zip Code:24614-9508
Practice Address - Country:US
Practice Address - Phone:276-935-2651
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist