Provider Demographics
NPI:1861723785
Name:MANLEY, JENNIFER
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MANLEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:825 S TAYLOR AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1567
Mailing Address - Country:US
Mailing Address - Phone:314-977-0150
Mailing Address - Fax:314-977-0023
Practice Address - Street 1:825 S TAYLOR AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1567
Practice Address - Country:US
Practice Address - Phone:314-977-0150
Practice Address - Fax:314-977-0023
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-15
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO468375506Medicaid