Healthcare Provider Details

I. General information

NPI: 1962926048
Provider Name (Legal Business Name): JENNA M MANN CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2017
Last Update Date: 02/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 DRIVING PARK AVE
NEWARK NY
14513
US

IV. Provider business mailing address

100 KINGS HWY S
ROCHESTER NY
14617-5504
US

V. Phone/Fax

Practice location:
  • Phone: 315-359-2847
  • Fax: 315-359-2806
Mailing address:
  • Phone: 585-922-0553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberSP017917
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number341400
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN692886
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: