Provider Demographics
NPI:1275603532
Name:MANIS, JEAN (LCSW)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:
Last Name:MANIS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:JEAN
Other - Middle Name:
Other - Last Name:MANIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:431 WEST 9TH STREET
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:IN
Mailing Address - Zip Code:46016-1317
Mailing Address - Country:US
Mailing Address - Phone:765-649-2234
Mailing Address - Fax:865-640-0538
Practice Address - Street 1:431 WEST 9TH STREET
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:IN
Practice Address - Zip Code:46016-1317
Practice Address - Country:US
Practice Address - Phone:765-649-2234
Practice Address - Fax:865-640-0538
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34003337A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN133450HMedicare ID - Type Unspecified