Provider Demographics
NPI:1821038928
Name:MAHAN, JACQUELINE F (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:F
Last Name:MAHAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1687 WOODLANE DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-3045
Mailing Address - Country:US
Mailing Address - Phone:651-209-6263
Mailing Address - Fax:651-209-6264
Practice Address - Street 1:1687 WOODLANE DR
Practice Address - Street 2:SUITE 101
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-3045
Practice Address - Country:US
Practice Address - Phone:651-209-6263
Practice Address - Fax:651-209-6264
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2018-05-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN40062207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN160056510OtherRR MEDICARE
MN0702247OtherMEDICA
MN585517900Medicaid
MN120389F210OtherUCARE
MNNA3501014502OtherPREFERRED ONE
MN0702247OtherSELECT CARE
WI34454200OtherWISCONSIN MEDICAID
MN56F15MAOtherBLUE CROSS BLUE SHIELD
MN764114OtherARAZ
MNG57651Medicare UPIN
MN160002030Medicare ID - Type Unspecified