Healthcare Provider Details

I. General information

NPI: 1053343350
Provider Name (Legal Business Name): JENNIFER MAHONEY CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 02/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 EUCLID AVE J 2 2
CLEVELAND OH
44195-0001
US

IV. Provider business mailing address

9500 EUCLID AVE J 2-2
CLEVELAND OH
44195-0001
US

V. Phone/Fax

Practice location:
  • Phone: 216-444-6483
  • Fax: 216-636-2700
Mailing address:
  • Phone: 216-444-6483
  • Fax: 216-445-3573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP07699
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberNP07699
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: