Provider Demographics
NPI:1649503293
Name:MANZ, JEAN MADELEINE (LMFT)
Entity type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:MADELEINE
Last Name:MANZ
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4773 SUNRISE CIR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:87401-9299
Mailing Address - Country:US
Mailing Address - Phone:505-716-7995
Mailing Address - Fax:
Practice Address - Street 1:3510 MESSINA DR
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:NM
Practice Address - Zip Code:87402-4782
Practice Address - Country:US
Practice Address - Phone:505-716-7995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-15
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0101581106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist