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General NPI Number Information
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NPI Number | 1407536956
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Entity Type | Individual
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Provider Name | JADEKA MOTLEY MANGRUM PMHNP
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Gender | Female
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Dates
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Enumeration Date | 07/19/2023
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Last Update Date | 07/20/2023
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Provider Practice Location Address
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Address Line | 700 WALTER REED DR
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City | GREENSBORO
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State | NC
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Zip | 27403-1128
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Country | US
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Telephone | 336-210-5641
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Fax |
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Provider Business Mailing Address
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Address Line | 700 GLENDALE DR APT H
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City | GREENSBORO
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State | NC
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Zip | 27406-6469
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Country | US
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Telephone | 362-105-6413
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 5018483
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License Number State | NC
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