MEDICARE: JORDAN NICOLE MAHANEY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program		OK

General Provider Information

NPI Number	:	1457179715
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JORDAN NICOLE MAHANEY

Provider Business Mailing Address
First Line	:	800 N OKLAHOMA AVE APT 1304
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73104-4413
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 N OKLAHOMA AVE APT 1304
Second Line	:
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73104-4413
Country	:	US
Telephone Number	:	972-971-2712
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/26/2024
Last Update Date	:	09/26/2024

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