Provider Demographics
NPI:1124868195
Name:MANGANO, JESSICA MARIE (MED)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:MARIE
Last Name:MANGANO
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4730 BRIARWOOD DR
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37416-3114
Mailing Address - Country:US
Mailing Address - Phone:317-629-7227
Mailing Address - Fax:
Practice Address - Street 1:6216 DAYTON BLVD STE D
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-2766
Practice Address - Country:US
Practice Address - Phone:423-521-5126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-28
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7291101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional