MEDICARE: JASMINE MANZANO APRN

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	363L00000X	Nurse Practitioner	209.029183	IL

General Provider Information

NPI Number	:	1447011994
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASMINE MANZANO APRN

Provider Business Mailing Address
First Line	:	5218 WILLOW CT
Second Line	:
City	:	GURNEE
State	:	IL
Zip	:	60031-1876
Country	:	US
Telephone Number	:	224-321-7172
Fax Number	:

Provider Business Practice Location Address
First Line	:	2659 N ELSTON AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-2018
Country	:	US
Telephone Number	:	773-352-8710
Fax Number	:

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

Provider Enumeration Date	:	01/22/2024
Last Update Date	:	01/22/2024

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