Provider Demographics
NPI:1407360530
Name:MAHANNAH, JENNIFER SHAWN (FNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:SHAWN
Last Name:MAHANNAH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IL
Mailing Address - Zip Code:61856-2116
Mailing Address - Country:US
Mailing Address - Phone:217-762-6241
Mailing Address - Fax:217-762-1702
Practice Address - Street 1:1000 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IL
Practice Address - Zip Code:61856-2116
Practice Address - Country:US
Practice Address - Phone:217-762-6241
Practice Address - Fax:217-762-1702
Is Sole Proprietor?:No
Enumeration Date:2017-11-28
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209016787363LF0000X
IL20901687363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily