Provider Demographics
NPI:1093060204
Name:MANGUS, JESSICA MICHELLE (DPT)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:MICHELLE
Last Name:MANGUS
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 S 5TH ST
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633-2434
Mailing Address - Country:US
Mailing Address - Phone:307-358-9464
Mailing Address - Fax:307-358-9330
Practice Address - Street 1:111 S 5TH ST
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:WY
Practice Address - Zip Code:82633-2434
Practice Address - Country:US
Practice Address - Phone:307-358-9464
Practice Address - Fax:307-358-9330
Is Sole Proprietor?:No
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPT-1438225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist