Provider Demographics
NPI:1033875778
Name:MANKE, JESSICA (PTA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MANKE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4528 E LAKE RD
Mailing Address - Street 2:
Mailing Address - City:CAZENOVIA
Mailing Address - State:NY
Mailing Address - Zip Code:13035-9387
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4528 E LAKE RD
Practice Address - Street 2:
Practice Address - City:CAZENOVIA
Practice Address - State:NY
Practice Address - Zip Code:13035-9387
Practice Address - Country:US
Practice Address - Phone:818-606-6253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010008225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant