Healthcare Provider Details

I. General information

NPI: 1255393823
Provider Name (Legal Business Name): JANE THERESA MCDONALD ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/06/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 CENTRE ST
MILTON MA
02186-3338
US

IV. Provider business mailing address

122 C WEST 7TH ST.
SOUTH BOSTON MA
02127
US

V. Phone/Fax

Practice location:
  • Phone: 617-898-2162
  • Fax:
Mailing address:
  • Phone: 857-225-2052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1193
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: