Provider Demographics
NPI:1144627092
Name:MANGUM, JENNEE JEANETTE (SSW)
Entity type:Individual
Prefix:
First Name:JENNEE
Middle Name:JEANETTE
Last Name:MANGUM
Suffix:
Gender:F
Credentials:SSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 867
Mailing Address - Street 2:
Mailing Address - City:PRICE
Mailing Address - State:UT
Mailing Address - Zip Code:84501-0867
Mailing Address - Country:US
Mailing Address - Phone:435-637-7200
Mailing Address - Fax:435-637-2377
Practice Address - Street 1:45 E. 100 S.
Practice Address - Street 2:
Practice Address - City:CASTLE DALE
Practice Address - State:UT
Practice Address - Zip Code:84513
Practice Address - Country:US
Practice Address - Phone:435-371-2432
Practice Address - Fax:435-371-2542
Is Sole Proprietor?:No
Enumeration Date:2014-11-20
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9121934-3503104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker