Provider Demographics
NPI:1720281546
Name:MCCONOLOGUE, JEANNE M (PA-C)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:M
Last Name:MCCONOLOGUE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 PUFFER ST
Mailing Address - Street 2:
Mailing Address - City:ASHBURNHAM
Mailing Address - State:MA
Mailing Address - Zip Code:01430-1267
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:50 MEMORIAL DR
Practice Address - Street 2:SUITE 205
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-2238
Practice Address - Country:US
Practice Address - Phone:978-534-4241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA432363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA509498Medicare UPIN