Provider Demographics
NPI:1912370172
Name:MANGUAL, JESSICA
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:MANGUAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2405 NE 88TH AVE
Mailing Address - Street 2:UNIT A
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97220-5434
Mailing Address - Country:US
Mailing Address - Phone:503-803-2080
Mailing Address - Fax:
Practice Address - Street 1:2405 NE 88TH AVE
Practice Address - Street 2:UNIT A
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97220-5434
Practice Address - Country:US
Practice Address - Phone:503-803-2080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program