Provider Demographics
NPI:1043857857
Name:MANLEY, JENNIFER (RD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MANLEY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18351 W VERDIN RD
Mailing Address - Street 2:
Mailing Address - City:GOODYEAR
Mailing Address - State:AZ
Mailing Address - Zip Code:85338-5078
Mailing Address - Country:US
Mailing Address - Phone:623-451-2580
Mailing Address - Fax:
Practice Address - Street 1:18351 W VERDIN RD
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85338-5078
Practice Address - Country:US
Practice Address - Phone:623-451-2580
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-01
Last Update Date:2019-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ85007766133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered