Provider Demographics
NPI:1871682609
Name:DONOHUE, JACQUELINE EMILIE
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:EMILIE
Last Name:DONOHUE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 PINE ST
Mailing Address - Street 2:5
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01851-3155
Mailing Address - Country:US
Mailing Address - Phone:978-454-1092
Mailing Address - Fax:978-952-6226
Practice Address - Street 1:531 KING ST
Practice Address - Street 2:4
Practice Address - City:LITTLETON
Practice Address - State:MA
Practice Address - Zip Code:01460-1279
Practice Address - Country:US
Practice Address - Phone:978-952-6336
Practice Address - Fax:978-952-6226
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1077131041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA108987OtherTRICARE
MAP07190OtherBLUE CROSS/BLUE SHIELD
MA108987OtherTRICARE