Healthcare Provider Details

I. General information

NPI: 1265769509
Provider Name (Legal Business Name): JOLENE MARIE MCMANUS B.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2009
Last Update Date: 11/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 MICHIGAN AVE.
OROFINO ID
83544
US

IV. Provider business mailing address

PO BOX 147 180 MICHIGAN AVE.
OROFINO ID
83544
US

V. Phone/Fax

Practice location:
  • Phone: 208-476-3921
  • Fax: 208-476-3921
Mailing address:
  • Phone: 208-476-3921
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberHA-1604
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: