Provider Demographics
NPI:1790107928
Name:MOONEYHAN, JENNINGS E (SA-C)
Entity Type:Individual
Prefix:MR
First Name:JENNINGS
Middle Name:E
Last Name:MOONEYHAN
Suffix:
Gender:M
Credentials:SA-C
Other - Prefix:MR
Other - First Name:JENNINGS
Other - Middle Name:E
Other - Last Name:MOONEYHAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:SA-C
Mailing Address - Street 1:1310 1ST ST S
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-6404
Mailing Address - Country:US
Mailing Address - Phone:904-222-5491
Mailing Address - Fax:904-627-1609
Practice Address - Street 1:1310 1ST ST S
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-6404
Practice Address - Country:US
Practice Address - Phone:904-222-5491
Practice Address - Fax:904-627-1609
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-07
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN94-122246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant