Healthcare Provider Details

I. General information

NPI: 1457788572
Provider Name (Legal Business Name): JERAMY MAHONEY DNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2013
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6600 VAN AALST BLVD
FORT BENNING GA
31905-2102
US

IV. Provider business mailing address

4301 JONES BRIDGE ROAD
BETHESDA MD
20814-4977
US

V. Phone/Fax

Practice location:
  • Phone: 706-544-5913
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number7165938-3102
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number7165938-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: