Healthcare Provider Details

I. General information

NPI: 1174098180
Provider Name (Legal Business Name): JENNIFER J MANSON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2018
Last Update Date: 12/27/2022
Certification Date: 12/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 NW MEDICAL LOOP STE 1&2
ROSEBURG OR
97471-8822
US

IV. Provider business mailing address

2370 CORPORATE CIR STE 300
HENDERSON NV
89074-7760
US

V. Phone/Fax

Practice location:
  • Phone: 541-537-8007
  • Fax:
Mailing address:
  • Phone: 702-910-3950
  • Fax: 702-786-6650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number200441163RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: