Provider Demographics
NPI:1063644623
Name:MANN, JENNIFER HAGAN (CRNP)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:HAGAN
Last Name:MANN
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:564 N MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:PRATTVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36067-2132
Mailing Address - Country:US
Mailing Address - Phone:334-358-2010
Mailing Address - Fax:334-358-2013
Practice Address - Street 1:213 LIGHTWOOD RD STE 1
Practice Address - Street 2:
Practice Address - City:DEATSVILLE
Practice Address - State:AL
Practice Address - Zip Code:36022-3800
Practice Address - Country:US
Practice Address - Phone:334-543-4164
Practice Address - Fax:334-543-4165
Is Sole Proprietor?:No
Enumeration Date:2009-08-17
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-100304363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1-100304OtherLICENSE NUMBER