Provider Demographics
NPI:1235707613
Name:MANN, JESSE R (CDCA)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:R
Last Name:MANN
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3433 AGLER RD STE 2100
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43219-3389
Mailing Address - Country:US
Mailing Address - Phone:614-599-6869
Mailing Address - Fax:614-413-3464
Practice Address - Street 1:3433 AGLER RD STE 2100
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43219-3389
Practice Address - Country:US
Practice Address - Phone:614-599-6869
Practice Address - Fax:614-413-3464
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.171611101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)