Healthcare Provider Details

I. General information

NPI: 1629944087
Provider Name (Legal Business Name): JESSICA ERIN MAHANEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2025
Last Update Date: 10/14/2025
Certification Date: 10/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 STATE ST
ROCHESTER NY
14614-1353
US

IV. Provider business mailing address

25 IRONSTONE DR
ROCHESTER NY
14624-4702
US

V. Phone/Fax

Practice location:
  • Phone: 585-454-3550
  • Fax:
Mailing address:
  • Phone: 585-454-3550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number318086-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: