MEDICARE: MR. JENNINGS E. MOONEYHAN SA-C

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	246ZC0007X	Surgical Assistant	94-122	TN

General Provider Information

NPI Number	:	1790107928
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JENNINGS E. MOONEYHAN SA-C

Provider Business Mailing Address
First Line	:	1310 1ST ST S
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-6404
Country	:	US
Telephone Number	:	904-222-5491
Fax Number	:	904-627-1609

Provider Business Practice Location Address
First Line	:	1310 1ST ST S
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-6404
Country	:	US
Telephone Number	:	904-222-5491
Fax Number	:	904-627-1609

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

Provider Enumeration Date	:	01/07/2014
Last Update Date	:	01/07/2014

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