Provider Demographics
NPI:1659887156
Name:MANZANARES, JENNY
Entity Type:Individual
Prefix:
First Name:JENNY
Middle Name:
Last Name:MANZANARES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10373 NE HANCOCK ST STE 106
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-3894
Mailing Address - Country:US
Mailing Address - Phone:503-922-2377
Mailing Address - Fax:
Practice Address - Street 1:10373 NE HANCOCK ST STE 106
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-3894
Practice Address - Country:US
Practice Address - Phone:503-922-2377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-19
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
OR16-CRM-226175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)