Provider Demographics
NPI:1306491576
Name:MAHANEY, JESSICA
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MAHANEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 LEAYOU RD
Mailing Address - Street 2:
Mailing Address - City:ALVATON
Mailing Address - State:KY
Mailing Address - Zip Code:42122-9634
Mailing Address - Country:US
Mailing Address - Phone:270-792-0400
Mailing Address - Fax:
Practice Address - Street 1:1830 DESTINY LN STE 112
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-1089
Practice Address - Country:US
Practice Address - Phone:270-792-0400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2543211041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical