Provider Demographics
NPI:1124314125
Name:DONNELLY, JESSICA M (MA)
Entity type:Individual
Prefix:MS
First Name:JESSICA
Middle Name:M
Last Name:DONNELLY
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 SUMMER STREET
Mailing Address - Street 2:
Mailing Address - City:RANDOLPH
Mailing Address - State:VT
Mailing Address - Zip Code:05060-7149
Mailing Address - Country:US
Mailing Address - Phone:802-735-2275
Mailing Address - Fax:
Practice Address - Street 1:2 SUMMER ST
Practice Address - Street 2:SUITE 3
Practice Address - City:RANDOLPH
Practice Address - State:VT
Practice Address - Zip Code:05060-1173
Practice Address - Country:US
Practice Address - Phone:802-735-2275
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-28
Last Update Date:2017-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT047-0072459103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist