Provider Demographics
NPI:1063976017
Name:MCDONALD, JENNIFER JO
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:JO
Last Name:MCDONALD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2220 UNIVERSITY DR SE
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44646-7443
Mailing Address - Country:US
Mailing Address - Phone:330-316-9170
Mailing Address - Fax:
Practice Address - Street 1:360 WABASH AVE N
Practice Address - Street 2:
Practice Address - City:BREWSTER
Practice Address - State:OH
Practice Address - Zip Code:44613-1042
Practice Address - Country:US
Practice Address - Phone:330-767-4179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-23
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH09623225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant