Provider Demographics
NPI:1972244036
Name:DONOVAN, JERILYN
Entity Type:Individual
Prefix:
First Name:JERILYN
Middle Name:
Last Name:DONOVAN
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 1:7 BRISTOL CT
Mailing Address - Street 2:
Mailing Address - City:WASHINGTONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10992-1366
Mailing Address - Country:US
Mailing Address - Phone:845-630-9318
Mailing Address - Fax:
Practice Address - Street 1:146 PIKE ST
Practice Address - Street 2:
Practice Address - City:PORT JERVIS
Practice Address - State:NY
Practice Address - Zip Code:12771-1808
Practice Address - Country:US
Practice Address - Phone:845-858-1456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program