Provider Demographics
NPI:1891017281
Name:MCMAHON, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MCMAHON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 STONELEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:CARMEL
Mailing Address - State:NY
Mailing Address - Zip Code:10512-3997
Mailing Address - Country:US
Mailing Address - Phone:845-279-5711
Mailing Address - Fax:
Practice Address - Street 1:670 STONELEIGH AVE
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:NY
Practice Address - Zip Code:10512-3997
Practice Address - Country:US
Practice Address - Phone:845-279-5711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-25
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY48473183500000X
CTPCT.0009337183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist