MEDICARE: JOLENE DONALDSON

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	106E00000X	Assistant Behavior Analyst

General Provider Information

NPI Number	:	1417449760
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOLENE DONALDSON

Provider Business Mailing Address
First Line	:	4906 DARBY LN
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29579-3199
Country	:	US
Telephone Number	:	843-593-6806
Fax Number	:

Provider Business Practice Location Address
First Line	:	4906 DARBY LN
Second Line	:
City	:	MYRTLE BEACH
State	:	SC
Zip	:	29579-3199
Country	:	US
Telephone Number	:	843-593-6806
Fax Number	:

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

Provider Enumeration Date	:	06/02/2018
Last Update Date	:	06/16/2018

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Directions to “ JOLENE DONALDSON ” Practice Location

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