Provider Demographics
NPI:1982828802
Name:MCDONNELL, JEROME P
Entity Type:Individual
Prefix:DR
First Name:JEROME
Middle Name:P
Last Name:MCDONNELL
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 1:2731 77TH AVE SE STE 205
Mailing Address - Street 2:
Mailing Address - City:MERCER ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98040-2800
Mailing Address - Country:US
Mailing Address - Phone:206-232-5100
Mailing Address - Fax:206-275-3716
Practice Address - Street 1:2731 77TH AVE SE STE 205
Practice Address - Street 2:
Practice Address - City:MERCER ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98040-2800
Practice Address - Country:US
Practice Address - Phone:206-232-5100
Practice Address - Fax:206-275-3716
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA44661223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA5011945Medicaid