Provider Demographics
NPI:1316762230
Name:MCMAHON, JENNIFER LYNNE
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNNE
Last Name:MCMAHON
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 1:501 GARLAND ST
Mailing Address - Street 2:
Mailing Address - City:DAVISON
Mailing Address - State:MI
Mailing Address - Zip Code:48423-1328
Mailing Address - Country:US
Mailing Address - Phone:810-730-3672
Mailing Address - Fax:
Practice Address - Street 1:219 N MAIN ST
Practice Address - Street 2:
Practice Address - City:DAVISON
Practice Address - State:MI
Practice Address - Zip Code:48423-1431
Practice Address - Country:US
Practice Address - Phone:810-412-4573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-15
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502003039225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant