Provider Demographics
NPI:1871718429
Name:MAHONEY, JEANNE TEDRA
Entity type:Individual
Prefix:MRS
First Name:JEANNE
Middle Name:TEDRA
Last Name:MAHONEY
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:JEANNE
Other - Middle Name:TEDRA
Other - Last Name:MAHONEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:1815 MCGUIRE CT
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-1949
Mailing Address - Country:US
Mailing Address - Phone:703-593-5194
Mailing Address - Fax:
Practice Address - Street 1:1364 BEVERLY RD
Practice Address - Street 2:SUITE 304
Practice Address - City:MCLEAN
Practice Address - State:VA
Practice Address - Zip Code:22101-3600
Practice Address - Country:US
Practice Address - Phone:703-593-5194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA09040062281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical