Healthcare Provider Details

I. General information

NPI: 1063936748
Provider Name (Legal Business Name): JACOB MANNING
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 12/30/2021
Certification Date: 12/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

259 SOUTHLAND DR
LEXINGTON KY
40503-1934
US

IV. Provider business mailing address

259 SOUTHLAND DR
LEXINGTON KY
40503-1934
US

V. Phone/Fax

Practice location:
  • Phone: 859-377-0491
  • Fax:
Mailing address:
  • Phone: 859-377-0491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number101835
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: