MEDICARE: MRS. JEANINE ANN MCDONELL DPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2251S0007X	Sports Physical Therapist	295914	CA
2	2251X0800X	Orthopedic Physical Therapist	295914	CA
3	225100000X	Physical Therapist	295914	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	295914	OTHER	CA	STATE LICENSE

General Provider Information

NPI Number	:	1467921452
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JEANINE ANN MCDONELL DPT

Provider Business Mailing Address
First Line	:	5720 RALSTON ST STE 200
Second Line	:
City	:	VENTURA
State	:	CA
Zip	:	93003-7844
Country	:	US
Telephone Number	:	805-804-4168
Fax Number	:	805-830-1177

Provider Business Practice Location Address
First Line	:	3901 LAS POSAS RD STE 8
Second Line	:
City	:	CAMARILLO
State	:	CA
Zip	:	93010-1502
Country	:	US
Telephone Number	:	805-585-3607
Fax Number	:	805-384-1786

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/19/2018
Last Update Date	:	11/27/2021

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