Provider Demographics
NPI:1972354199
Name:DONNELLY, MATTHEW JAE
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAE
Last Name:DONNELLY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2442 MOORESVILLE PIKE
Mailing Address - Street 2:
Mailing Address - City:CULLEOKA
Mailing Address - State:TN
Mailing Address - Zip Code:38451-2159
Mailing Address - Country:US
Mailing Address - Phone:410-517-9906
Mailing Address - Fax:
Practice Address - Street 1:384 CARRIAGE HOUSE DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2268
Practice Address - Country:US
Practice Address - Phone:731-868-7297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-27
Last Update Date:2024-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2459101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health