Provider Demographics
NPI:1003188970
Name:MOHON, JENNY RAE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:RAE
Last Name:MOHON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1515N LAWRIE TATUM ROAD
Mailing Address - Street 2:USPHS LAWTON INDIAN HOSPITAL
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507
Mailing Address - Country:US
Mailing Address - Phone:580-353-0350
Mailing Address - Fax:
Practice Address - Street 1:1515 NORTH EAST LAWRIE TATUM ROAD
Practice Address - Street 2:USPHS LAWTON INDIAN HOSPITAL
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507
Practice Address - Country:US
Practice Address - Phone:580-353-0350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-07
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16427363LA2200X
TN134293163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse