Basic Information
Provider Information | |||||||||
NPI: | 1881835288 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCMAHAN | ||||||||
FirstName: | JENNIFER | ||||||||
MiddleName: | J | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WEST | ||||||||
OtherFirstName: | JENNIFER | ||||||||
OtherMiddleName: | J | ||||||||
OtherNamePrefix: | MISS | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | CRNA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 4488 | ||||||||
Address2: |   | ||||||||
City: | SPRINGFIELD | ||||||||
State: | IL | ||||||||
PostalCode: | 627084488 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8005775368 | ||||||||
FaxNumber: | 2177572021 | ||||||||
Practice Location | |||||||||
Address1: | 701 N 1ST ST | ||||||||
Address2: | ANESTHESIA DEPARTMENT | ||||||||
City: | SPRINGFIELD | ||||||||
State: | IL | ||||||||
PostalCode: | 627810001 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2177883754 | ||||||||
FaxNumber: | 2177887071 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/13/2009 | ||||||||
LastUpdateDate: | 07/23/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 209007518 | IL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 081072 | 01 | IL | ANCC CERTIFICATION NUMBER | OTHER |