Provider Demographics
NPI:1013914308
Name:MANCINI, JEAN MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:JEAN
Middle Name:MARIE
Last Name:MANCINI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37662-0009
Mailing Address - Country:US
Mailing Address - Phone:423-857-2066
Mailing Address - Fax:423-857-2070
Practice Address - Street 1:1 MEDICAL PARK BLVD
Practice Address - Street 2:STE 450W
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7430
Practice Address - Country:US
Practice Address - Phone:423-968-3713
Practice Address - Fax:423-986-7352
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN038379207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
4091342OtherBCTN
TN3896190Medicaid
010105765OtherVA MEDICAID
TN103I118140Medicare PIN
4091342OtherBCTN
3896190Medicare ID - Type Unspecified