Provider Demographics
NPI:1811540974
Name:MAHONEY, JACQUELINE COOPER (PHD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:COOPER
Last Name:MAHONEY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:COOPER
Other - Last Name:REYNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:20981 COASTAL HWY # 12
Mailing Address - Street 2:
Mailing Address - City:REHOBOTH BEACH
Mailing Address - State:DE
Mailing Address - Zip Code:19971-8003
Mailing Address - Country:US
Mailing Address - Phone:202-203-9541
Mailing Address - Fax:
Practice Address - Street 1:515 BROAD ST
Practice Address - Street 2:
Practice Address - City:PERRYVILLE
Practice Address - State:MD
Practice Address - Zip Code:21903-2734
Practice Address - Country:US
Practice Address - Phone:410-642-2411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-18
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEB10001179103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical