Provider Demographics
NPI:1255521324
Name:MCDONELL, JONATHAN WILLIAM (LAC, LMT, PTA)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:WILLIAM
Last Name:MCDONELL
Suffix:
Gender:M
Credentials:LAC, LMT, PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 BEACH RD
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-1756
Mailing Address - Country:US
Mailing Address - Phone:716-984-0899
Mailing Address - Fax:
Practice Address - Street 1:704 BEACH RD
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14225-1756
Practice Address - Country:US
Practice Address - Phone:716-984-0899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003605-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist