Provider Demographics
NPI:1104662253
Name:MCSHANE, JENNIFER N/A
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:N/A
Last Name:MCSHANE
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:PO BOX 13166
Mailing Address - Street 2:
Mailing Address - City:MAUMELLE
Mailing Address - State:AR
Mailing Address - Zip Code:72113-0166
Mailing Address - Country:US
Mailing Address - Phone:501-508-1404
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 13166
Practice Address - Street 2:
Practice Address - City:MAUMELLE
Practice Address - State:AR
Practice Address - Zip Code:72113-0166
Practice Address - Country:US
Practice Address - Phone:501-508-1404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-08
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver