=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891371944
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNI LOU MCCANN PMHNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/19/2021
-----------------------------------------------------
Last Update Date | 10/12/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2600 DODGE ST STE D5
-----------------------------------------------------
City | DUBUQUE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52003-7161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-590-1399
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2600 DODGE ST STE D5
-----------------------------------------------------
City | DUBUQUE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52003-7161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 563-590-1399
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | G162931
-----------------------------------------------------
License Number State | IA
-----------------------------------------------------