Provider Demographics
NPI:1275902587
Name:MAHON, JENNIFER (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MAHON
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:MAHON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:REGISTERED NURSE
Mailing Address - Street 1:116 WAVERLY AVE
Mailing Address - Street 2:
Mailing Address - City:PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-2186
Mailing Address - Country:US
Mailing Address - Phone:631-475-7108
Mailing Address - Fax:631-475-9601
Practice Address - Street 1:116 WAVERLY AVE
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-2186
Practice Address - Country:US
Practice Address - Phone:631-475-7108
Practice Address - Fax:631-475-9601
Is Sole Proprietor?:No
Enumeration Date:2015-09-16
Last Update Date:2024-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY577795-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY33-4013Medicare PIN