Provider Demographics
NPI:1164940599
Name:JEAN MANZ COACHING, LLC
Entity Type:Organization
Organization Name:JEAN MANZ COACHING, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:MADELEINE
Authorized Official - Last Name:MANZ
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:505-716-7995
Mailing Address - Street 1:4773 SUNRISE CIR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-9299
Mailing Address - Country:US
Mailing Address - Phone:505-716-7995
Mailing Address - Fax:
Practice Address - Street 1:3510 MESSINA DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-4782
Practice Address - Country:US
Practice Address - Phone:505-716-7995
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-06
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0101581261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)