Provider Demographics
NPI:1063006286
Name:MANUEL, JENNA MAE
Entity Type:Individual
Prefix:
First Name:JENNA MAE
Middle Name:
Last Name:MANUEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4440 ALAMO ST
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-1733
Mailing Address - Country:US
Mailing Address - Phone:805-522-3120
Mailing Address - Fax:805-522-4074
Practice Address - Street 1:4440 ALAMO ST
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93063-1733
Practice Address - Country:US
Practice Address - Phone:805-522-3120
Practice Address - Fax:805-522-4074
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-28
Last Update Date:2021-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CATCH76132183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician