Provider Demographics
NPI:1003823600
Name:MANGAN, JENNIFER NICOLE (DC)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:NICOLE
Last Name:MANGAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13955 W PRESERVE BLVD # 200
Mailing Address - Street 2:
Mailing Address - City:BURNSVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55337-7733
Mailing Address - Country:US
Mailing Address - Phone:952-890-0804
Mailing Address - Fax:952-890-1095
Practice Address - Street 1:13955 W PRESERVE BLVD # 200
Practice Address - Street 2:
Practice Address - City:BURNSVILLE
Practice Address - State:MN
Practice Address - Zip Code:55337-7733
Practice Address - Country:US
Practice Address - Phone:952-890-0804
Practice Address - Fax:952-890-1095
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4585111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN499T6MAOtherBCBS PRIVODER NUMBER
MNV00678Medicare UPIN