Provider Demographics
NPI:1639595762
Name:MANN, JENNIFER (LCDC II, OCPSI)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:MANN
Suffix:
Gender:F
Credentials:LCDC II, OCPSI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1495 SUNFLOWER RD
Mailing Address - Street 2:
Mailing Address - City:NEW CONCORD
Mailing Address - State:OH
Mailing Address - Zip Code:43762-9671
Mailing Address - Country:US
Mailing Address - Phone:614-394-6047
Mailing Address - Fax:855-692-7247
Practice Address - Street 1:1225 WOODLAWN AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:OH
Practice Address - Zip Code:43725-3094
Practice Address - Country:US
Practice Address - Phone:855-692-7247
Practice Address - Fax:855-692-7247
Is Sole Proprietor?:No
Enumeration Date:2014-03-13
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOCPS.1204.1101YA0400X
OHLCDC.081250-02101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)