Provider Demographics
NPI:1376637728
Name:MCCLANAHAN, JEANIE LARUE
Entity Type:Individual
Prefix:
First Name:JEANIE
Middle Name:LARUE
Last Name:MCCLANAHAN
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:HC1 BOX 160B1
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63633
Mailing Address - Country:US
Mailing Address - Phone:573-924-2286
Mailing Address - Fax:
Practice Address - Street 1:115 WALNUT ST.
Practice Address - Street 2:
Practice Address - City:ELLINGTON
Practice Address - State:MO
Practice Address - Zip Code:63638
Practice Address - Country:US
Practice Address - Phone:573-663-3177
Practice Address - Fax:573-663-3188
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant