1336271451 NPI number — JENNIFER MOHAN PA

Table of content: JENNIFER MOHAN PA (NPI 1336271451)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1336271451 NPI number — JENNIFER MOHAN PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOHAN
Provider First Name:
JENNIFER
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1336271451
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/24/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2160 COLONIAL BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MYERS
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33907-1410
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
239-931-7342
Provider Business Mailing Address Fax Number:
239-931-7385

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
21150 BISCAYNE BLVD STE 404
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AVENTURA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33180-1250
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
305-466-9111
Provider Business Practice Location Address Fax Number:
786-248-0038
Provider Enumeration Date:
03/12/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA9101096 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 174400000X , with the licence number: PA9101096 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 101287700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".