Provider Demographics
NPI:1568605087
Name:MAZZOLINI, JEANANNE (RT (R) (M))
Entity Type:Individual
Prefix:MRS
First Name:JEANANNE
Middle Name:
Last Name:MAZZOLINI
Suffix:
Gender:F
Credentials:RT (R) (M)
Other - Prefix:MS
Other - First Name:JEANANNE
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5066
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88102-5066
Mailing Address - Country:US
Mailing Address - Phone:575-693-3770
Mailing Address - Fax:575-763-5411
Practice Address - Street 1:2105 WEST 21ST STREET
Practice Address - Street 2:SUITE A
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-4086
Practice Address - Country:US
Practice Address - Phone:575-693-3770
Practice Address - Fax:575-763-5411
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-14
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMRRT 1505247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist