Provider Demographics
NPI:1548733140
Name:MANGS, JESSIE T (PA)
Entity type:Individual
Prefix:
First Name:JESSIE
Middle Name:T
Last Name:MANGS
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:1290 SILAS DEANE HWY STE 102
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-4337
Mailing Address - Country:US
Mailing Address - Phone:860-972-6977
Mailing Address - Fax:860-972-7040
Practice Address - Street 1:481 BANTAM RD
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:CT
Practice Address - Zip Code:06759-3202
Practice Address - Country:US
Practice Address - Phone:860-567-1263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-07
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CT363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical