Provider Demographics
NPI:1205281565
Name:MCMAHON, JODY ANN
Entity type:Individual
Prefix:
First Name:JODY
Middle Name:ANN
Last Name:MCMAHON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JODY
Other - Middle Name:ANN
Other - Last Name:FLOOD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14850 QUORUM DR
Mailing Address - Street 2:120
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-7566
Mailing Address - Country:US
Mailing Address - Phone:844-325-7722
Mailing Address - Fax:214-242-8063
Practice Address - Street 1:22250 PROVIDENCE DR
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4825
Practice Address - Country:US
Practice Address - Phone:248-849-3939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-24
Last Update Date:2016-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704263050367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered