Provider Demographics
NPI:1568785368
Name:MANGINE, JENNIFER JOHNSON (BA, RAS,SUDC-C)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:JOHNSON
Last Name:MANGINE
Suffix:
Gender:F
Credentials:BA, RAS,SUDC-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1845 S COURT ST
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93277-5423
Mailing Address - Country:US
Mailing Address - Phone:559-732-5550
Mailing Address - Fax:
Practice Address - Street 1:1845 S COURT ST
Practice Address - Street 2:
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93277-5423
Practice Address - Country:US
Practice Address - Phone:559-732-5559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-08
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAM1202071247101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1995216Medicaid