Provider Demographics
NPI:1356937569
Name:MCDONALD, JERRY LAVELL (RPSGT, RST)
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:LAVELL
Last Name:MCDONALD
Suffix:
Gender:M
Credentials:RPSGT, RST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 BRISCO ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-4602
Mailing Address - Country:US
Mailing Address - Phone:601-519-1935
Mailing Address - Fax:
Practice Address - Street 1:2400 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:TUSKEGEE
Practice Address - State:AL
Practice Address - Zip Code:36083-5002
Practice Address - Country:US
Practice Address - Phone:334-727-0550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-12
Last Update Date:2020-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other