Provider Demographics
NPI:1417415084
Name:DONALDSON, JACQUELINE MCSALLY (PA-C)
Entity type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:MCSALLY
Last Name:DONALDSON
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:MARIE
Other - Last Name:MCSALLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:28 SHERMAN CIR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:CT
Mailing Address - Zip Code:06468-2121
Mailing Address - Country:US
Mailing Address - Phone:203-581-1522
Mailing Address - Fax:
Practice Address - Street 1:5520 PARK AVE
Practice Address - Street 2:
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-3463
Practice Address - Country:US
Practice Address - Phone:203-261-7262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-03
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-08914363A00000X
CT6876363AS0400X
WI7737-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1159850OtherNATIONAL COMMISSION ON CERTIFICATION OF PHYSICIAN ASSISTANTS (NCCPA)
110-622-459OtherAMERICAN ACADEMY OF PAS (AAPA)
WI100274093Medicaid