Provider Demographics
NPI:1861474777
Name:MANRY, JENNIFER (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:MANRY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:974 S ENOTA DR NE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-2429
Mailing Address - Country:US
Mailing Address - Phone:770-536-7546
Mailing Address - Fax:678-343-2006
Practice Address - Street 1:974 S ENOTA DR NE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-2429
Practice Address - Country:US
Practice Address - Phone:770-536-7546
Practice Address - Fax:678-343-2006
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003403363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP11354Medicare UPIN
GA97WCDXGMedicare ID - Type Unspecified