Provider Demographics
NPI:1134410434
Name:MANNING, JESSICA L (PHD)
Entity type:Individual
Prefix:DR
First Name:JESSICA
Middle Name:L
Last Name:MANNING
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 IONIA AVE SW, SUITE 500
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503
Mailing Address - Country:US
Mailing Address - Phone:616-365-8920
Mailing Address - Fax:
Practice Address - Street 1:15 IONIA AVE SW, SUITE 500
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:616-202-1234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-21
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20042522A103TC1900X, 103T00000X
MI6301016638103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling