Healthcare Provider Details

I. General information

NPI: 1598092629
Provider Name (Legal Business Name): JESSIE D MCDONALD II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2009
Last Update Date: 11/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

654 W IRIS DR
NASHVILLE TN
37204-3191
US

IV. Provider business mailing address

654 W IRIS DR
NASHVILLE TN
37204-3191
US

V. Phone/Fax

Practice location:
  • Phone: 615-269-5170
  • Fax: 615-269-8015
Mailing address:
  • Phone: 615-269-5170
  • Fax: 615-269-8015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: