Basic Information
| Provider Information | |||||||||
| NPI: | 1992800841 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCDONNELL | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | B.A. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEADER | ||||||||
| OtherFirstName: | JESSICA | ||||||||
| OtherMiddleName: | JEAN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 520555 | ||||||||
| Address2: | |||||||||
| City: | BIG LAKE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996520555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9078922332 | ||||||||
| FaxNumber: | 9078922332 | ||||||||
| Practice Location | |||||||||
| Address1: | 2735 E TUDOR RD | ||||||||
| Address2: | |||||||||
| City: | ANCHORAGE | ||||||||
| State: | AK | ||||||||
| PostalCode: | 995071135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9077628694 | ||||||||
| FaxNumber: | 9075627901 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.