Provider Demographics
NPI:1043207525
Name:MANNING, JERRY WAYNE (PT)
Entity Type:Individual
Prefix:MR
First Name:JERRY
Middle Name:WAYNE
Last Name:MANNING
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3016 W MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-2453
Mailing Address - Country:US
Mailing Address - Phone:479-967-9657
Mailing Address - Fax:479-967-9658
Practice Address - Street 1:3016 W MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-2453
Practice Address - Country:US
Practice Address - Phone:479-967-9657
Practice Address - Fax:479-967-9658
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04847R225100000X
ARPT2457225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1139955Medicaid
LA1139955Medicaid