Provider Demographics
NPI:1679942122
Name:MAHONEY, JENNIFER THERESE (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:THERESE
Last Name:MAHONEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2845 GREENBRIER RD
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-6519
Mailing Address - Country:US
Mailing Address - Phone:920-288-4180
Mailing Address - Fax:920-288-4182
Practice Address - Street 1:2845 GREENBRIER RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6519
Practice Address - Country:US
Practice Address - Phone:920-288-4180
Practice Address - Fax:920-288-4182
Is Sole Proprietor?:No
Enumeration Date:2015-09-15
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3665-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1679942122Medicaid