Provider Demographics
NPI:1679078174
Name:MCNALLY, JESSICA J (MPA, AT, ATC)
Entity type:Individual
Prefix:MISS
First Name:JESSICA
Middle Name:J
Last Name:MCNALLY
Suffix:
Gender:F
Credentials:MPA, AT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5101 JOHN C LODGE FWY
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3327
Mailing Address - Country:US
Mailing Address - Phone:313-577-1008
Mailing Address - Fax:313-577-1012
Practice Address - Street 1:5101 JOHN C LODGE FWY
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3327
Practice Address - Country:US
Practice Address - Phone:313-577-1008
Practice Address - Fax:313-577-1012
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI26010010902255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer