Provider Demographics
NPI:1801395413
Name:MACDONALD, JESSICA (ATC)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MACDONALD
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 OAK RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:STANDISH
Mailing Address - State:ME
Mailing Address - Zip Code:04084-6017
Mailing Address - Country:US
Mailing Address - Phone:207-239-1237
Mailing Address - Fax:
Practice Address - Street 1:1301 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-5300
Practice Address - Country:US
Practice Address - Phone:207-239-1237
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-09
Last Update Date:2018-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260026932255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer