Provider Demographics
NPI:1104923341
Name:DONALDSON, JEANETTE
Entity type:Individual
Prefix:
First Name:JEANETTE
Middle Name:
Last Name:DONALDSON
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 1:106 PELICAN DR
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32951-3735
Mailing Address - Country:US
Mailing Address - Phone:321-723-1627
Mailing Address - Fax:
Practice Address - Street 1:5200 BABCOCK ST NE STE 400
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32905-4612
Practice Address - Country:US
Practice Address - Phone:321-984-9606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL6116OtherLICENSE #