Healthcare Provider Details

I. General information

NPI: 1194050534
Provider Name (Legal Business Name): JEANETTE MANCHESTER PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2009
Last Update Date: 08/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

399 E MAIN ST
COLUMBUS OH
43215-5384
US

IV. Provider business mailing address

PO BOX 715194
COLUMBUS OH
43271-5194
US

V. Phone/Fax

Practice location:
  • Phone: 614-355-8550
  • Fax: 614-355-8593
Mailing address:
  • Phone: 614-355-8004
  • Fax: 614-355-0509

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberC.1100560
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: