Provider Demographics
NPI:1164289740
Name:MANLEY, JILLIAN LEILYN (CMT)
Entity Type:Individual
Prefix:
First Name:JILLIAN
Middle Name:LEILYN
Last Name:MANLEY
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3291 FREI RD
Mailing Address - Street 2:
Mailing Address - City:SEBASTOPOL
Mailing Address - State:CA
Mailing Address - Zip Code:95472-2303
Mailing Address - Country:US
Mailing Address - Phone:916-541-1847
Mailing Address - Fax:
Practice Address - Street 1:103 MORRIS ST STE A1
Practice Address - Street 2:
Practice Address - City:SEBASTOPOL
Practice Address - State:CA
Practice Address - Zip Code:95472-3850
Practice Address - Country:US
Practice Address - Phone:916-541-1847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA84156225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist