Provider Demographics
NPI:1659924181
Name:MANZO, JESSICA BERENICE
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:BERENICE
Last Name:MANZO
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 1:250 DUNDEE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-1024
Mailing Address - Country:US
Mailing Address - Phone:650-200-7934
Mailing Address - Fax:
Practice Address - Street 1:1001 SNEATH LN STE 200
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-2349
Practice Address - Country:US
Practice Address - Phone:650-243-9849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-23
Last Update Date:2019-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician