MEDICARE: JACQUELINE ANN MANLEY LMFT

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	106H00000X	Marriage & Family Therapist	103200	CA
2	106H00000X	Marriage & Family Therapist	203440	TX

General Provider Information

NPI Number	:	1801452396
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE ANN MANLEY LMFT

Provider Business Mailing Address
First Line	:	10016 SHELBURNE RD
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76244-8524
Country	:	US
Telephone Number	:	619-818-6516
Fax Number	:

Provider Business Practice Location Address
First Line	:	9800 HILLWOOD PKWY STE 140
Second Line	:
City	:	FT WORTH
State	:	TX
Zip	:	76177-1532
Country	:	US
Telephone Number	:	619-818-6516
Fax Number	:

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

Provider Enumeration Date	:	05/10/2019
Last Update Date	:	05/10/2019

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