Provider Demographics
NPI:1538167341
Name:MCDONOUGH, JAMIE LYNN (PT)
Entity type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
Last Name:MCDONOUGH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:LYNN
Other - Last Name:WOLFE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:2101 NAGLE RD
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16510-2189
Mailing Address - Country:US
Mailing Address - Phone:814-877-7078
Mailing Address - Fax:814-899-5484
Practice Address - Street 1:2101 NAGLE RD
Practice Address - Street 2:UPMC CENTERS FOR REHAB SERVICES
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16510-2189
Practice Address - Country:US
Practice Address - Phone:814-877-7078
Practice Address - Fax:814-899-5484
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT013867L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1011581100001Medicaid
NY00027021401OtherUNIVERA
PA3762785OtherAETNA
PAP00170352OtherRR MEDICARE
PA1672791OtherBLUE SHIELD
Q34859Medicare UPIN
PA087769E7CMedicare PIN