Provider Demographics
NPI:1871178749
Name:MAHONEY, JORDAN TAYLOR (PA-C)
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:TAYLOR
Last Name:MAHONEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2486 SE TIFFANY AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-6560
Mailing Address - Country:US
Mailing Address - Phone:816-517-7495
Mailing Address - Fax:
Practice Address - Street 1:1400 SE GOLDTREE DR STE 103
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7582
Practice Address - Country:US
Practice Address - Phone:772-335-8446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-12
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9113759363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant