Provider Demographics
NPI:1598762734
Name:MANYAN, JESSICA CONLON (DO)
Entity Type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:CONLON
Last Name:MANYAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:7 HOMESTEAD ST
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860-4215
Mailing Address - Country:US
Mailing Address - Phone:401-837-4503
Mailing Address - Fax:508-673-5605
Practice Address - Street 1:67 SLADES FERRY AVE STE 6706
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:MA
Practice Address - Zip Code:02726-1220
Practice Address - Country:US
Practice Address - Phone:508-678-5633
Practice Address - Fax:508-673-5605
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RI0538207Q00000X
MA283425207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIJM50782Medicaid
RIH52618Medicare UPIN
RIJM50782Medicaid