Healthcare Provider Details

I. General information

NPI: 1346538030
Provider Name (Legal Business Name): JESSICA B MANESS LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2011
Last Update Date: 07/06/2024
Certification Date: 07/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45280 SEQUOIA RD
GUALALA CA
95445-8664
US

IV. Provider business mailing address

PO BOX 2077
GUALALA CA
95445-2077
US

V. Phone/Fax

Practice location:
  • Phone: 701-690-2798
  • Fax: 701-872-3748
Mailing address:
  • Phone: 701-690-2798
  • Fax: 707-703-5794

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number70687
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: