Healthcare Provider Details

I. General information

NPI: 1518736180
Provider Name (Legal Business Name): JENEL MANUEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/25/2023
Last Update Date: 02/12/2025
Certification Date: 02/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1708 FALL HILL AVE
FREDERICKSBURG VA
22401-3511
US

IV. Provider business mailing address

825 FAIRFAX AVE
NORFOLK VA
23507-1914
US

V. Phone/Fax

Practice location:
  • Phone: 562-405-9844
  • Fax:
Mailing address:
  • Phone: 757-446-5600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110010309
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number0110010309
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number0110010309
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: