=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629523253
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JENNIFER MANGER PH.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/24/2016
-----------------------------------------------------
Last Update Date | 08/25/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 715 ROUTE 10 E
-----------------------------------------------------
City | RANDOLPH
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07869-2025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-493-6822
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 715 ROUTE 10 E
-----------------------------------------------------
City | RANDOLPH
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07869-2025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 35SI00438900
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------