Provider Demographics
NPI:1740627033
Name:MANLY, JESSICA L (CNP)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:L
Last Name:MANLY
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:MANLY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CNP
Mailing Address - Street 1:444 N CLEVELAND AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43082-8389
Mailing Address - Country:US
Mailing Address - Phone:614-899-2700
Mailing Address - Fax:614-823-5656
Practice Address - Street 1:444 N CLEVELAND AVE
Practice Address - Street 2:STE 200
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-8389
Practice Address - Country:US
Practice Address - Phone:614-899-2700
Practice Address - Fax:614-823-5656
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-28
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.14510363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0123310Medicaid
OH0123310Medicaid