Healthcare Provider Details

I. General information

NPI: 1568785368
Provider Name (Legal Business Name): JENNIFER JOHNSON MANGINE B.A., RAS,SUDC-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2010
Last Update Date: 12/02/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1845 S COURT ST
VISALIA CA
93277-5423
US

IV. Provider business mailing address

1845 S COURT ST
VISALIA CA
93277-5423
US

V. Phone/Fax

Practice location:
  • Phone: 559-732-5559
  • Fax:
Mailing address:
  • Phone: 559-732-5550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberM1202071247
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: