Provider Demographics
NPI:1053343350
Name:MAHONEY, JENNIFER (CNP)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:MAHONEY
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9500 EUCLID AVE
Mailing Address - Street 2:J 2-2
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44195-0001
Mailing Address - Country:US
Mailing Address - Phone:216-444-6483
Mailing Address - Fax:216-445-3573
Practice Address - Street 1:9500 EUCLID AVE
Practice Address - Street 2:J 2 2
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-0001
Practice Address - Country:US
Practice Address - Phone:216-444-6483
Practice Address - Fax:216-636-2700
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP07699363L00000X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000344039OtherANTHEM BLUE CROSS/BLUE SH
OH7441606OtherAETNA
OH1001149OtherQUALCHOICE
OH107132OtherKAISER
OH341487428OtherTAX ID
OH2507684Medicaid
OHA60194OtherSUMMACARE
OHP00191907OtherRAILROAD MEDICARE
OH1001149OtherQUALCHOICE
OH107132OtherKAISER