1790107928 NPI number — MR. JENNINGS E. MOONEYHAN SA-C

Table of content: MR. JENNINGS E. MOONEYHAN SA-C (NPI 1790107928)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790107928 NPI number — MR. JENNINGS E. MOONEYHAN SA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOONEYHAN
Provider First Name:
JENNINGS
Provider Middle Name:
E.
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
SA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MOONEYHAN
Provider Other First Name:
JENNINGS
Provider Other Middle Name:
E
Provider Other Name Prefix Text:
MR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
SA-C
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1790107928
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/07/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1310 1ST ST S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSONVILLE BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32250-6404
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
904-222-5491
Provider Business Mailing Address Fax Number:
904-627-1609

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1310 1ST ST S
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSONVILLE BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32250-6404
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
904-222-5491
Provider Business Practice Location Address Fax Number:
904-627-1609
Provider Enumeration Date:
01/07/2014

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: 246ZC0007X , with the licence number:  94-122 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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