Provider Demographics
NPI:1699041269
Name:MCMAHON, JOLENE AUDREY (OTR/L)
Entity Type:Individual
Prefix:
First Name:JOLENE
Middle Name:AUDREY
Last Name:MCMAHON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26245 GOLDEN AVE
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MN
Mailing Address - Zip Code:55092-8026
Mailing Address - Country:US
Mailing Address - Phone:651-890-7990
Mailing Address - Fax:
Practice Address - Street 1:640 JACKSON ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2502
Practice Address - Country:US
Practice Address - Phone:651-254-2060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-28
Last Update Date:2012-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104114225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist