Provider Demographics
NPI:1790966208
Name:MANN, JESSICA SALAS (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:SALAS
Last Name:MANN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:SALAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:234 INDUSTRIAL WAY WEST
Mailing Address - Street 2:SUITE A104
Mailing Address - City:EATONTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:07724
Mailing Address - Country:US
Mailing Address - Phone:732-918-2500
Mailing Address - Fax:732-918-2504
Practice Address - Street 1:234 INDUSTRIAL WAY WEST
Practice Address - Street 2:SUITE A104
Practice Address - City:EATONTOWN
Practice Address - State:NJ
Practice Address - Zip Code:07724
Practice Address - Country:US
Practice Address - Phone:732-918-2500
Practice Address - Fax:732-918-2504
Is Sole Proprietor?:No
Enumeration Date:2007-11-27
Last Update Date:2014-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT045972207V00000X
NY257797207VE0102X
NJ25MA08947600207VE0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VE0102XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyReproductive Endocrinology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0347698Medicaid