Healthcare Provider Details

I. General information

NPI: 1861723785
Provider Name (Legal Business Name): JENNIFER MANLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JENNIFER JOHNSON

II. Dates (important events)

Enumeration Date: 01/15/2010
Last Update Date: 08/24/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 S TAYLOR AVE
SAINT LOUIS MO
63110-1567
US

IV. Provider business mailing address

825 S TAYLOR AVE
SAINT LOUIS MO
63110-1567
US

V. Phone/Fax

Practice location:
  • Phone: 314-977-0150
  • Fax: 314-977-0023
Mailing address:
  • Phone: 314-977-0150
  • Fax: 314-977-0023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: