Provider Demographics
NPI:1790986586
Name:MCDONOUGH, JESSICA ANN (OTRL)
Entity Type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:ANN
Last Name:MCDONOUGH
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2578 EASTMAN DR
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-4409
Mailing Address - Country:US
Mailing Address - Phone:507-251-8235
Mailing Address - Fax:
Practice Address - Street 1:22 27TH AVE SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55414-3102
Practice Address - Country:US
Practice Address - Phone:612-332-4262
Practice Address - Fax:612-339-4671
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN103157225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist