Provider Demographics
NPI:1780743187
Name:MANLEY, JENNIFER TARA (RD LDN)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:TARA
Last Name:MANLEY
Suffix:
Gender:F
Credentials:RD LDN
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Mailing Address - Street 1:19809 B NORTH COVE RD
Mailing Address - Street 2:STE 108
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031
Mailing Address - Country:US
Mailing Address - Phone:704-651-2666
Mailing Address - Fax:704-895-3673
Practice Address - Street 1:16501 NORTHCROSS DRIVE
Practice Address - Street 2:SUITE D
Practice Address - City:HUNTERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28078
Practice Address - Country:US
Practice Address - Phone:704-895-9865
Practice Address - Fax:704-895-9870
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NCL000635133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC139J5OtherBCBS
NC9220313OtherCIGNA