MEDICARE: MS. JEAN MANLOVE LICSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	02744	MN

General Provider Information

NPI Number	:	1235354531
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JEAN MANLOVE LICSW

Provider Business Mailing Address
First Line	:	8009 34TH AVE S
Second Line	:	SUITE 1490
City	:	BLOOMINGTON
State	:	MN
Zip	:	55425-1608
Country	:	US
Telephone Number	:	952-854-5550
Fax Number	:	952-854-5062

Provider Business Practice Location Address
First Line	:	8009 34TH AVE S
Second Line	:	SUITE 1490
City	:	BLOOMINGTON
State	:	MN
Zip	:	55425-1608
Country	:	US
Telephone Number	:	952-854-5550
Fax Number	:	952-854-5062

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2007
Last Update Date	:	07/08/2007

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