Provider Demographics
NPI:1215713599
Name:IMMANUEL MANOHAR, JENNIPHER (PMHNP, FNP)
Entity type:Individual
Prefix:
First Name:JENNIPHER
Middle Name:
Last Name:IMMANUEL MANOHAR
Suffix:
Gender:F
Credentials:PMHNP, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1631
Mailing Address - Street 2:
Mailing Address - City:ROANOKE RAPIDS
Mailing Address - State:NC
Mailing Address - Zip Code:27870-7631
Mailing Address - Country:US
Mailing Address - Phone:803-450-8862
Mailing Address - Fax:
Practice Address - Street 1:2715 COLONIAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6818
Practice Address - Country:US
Practice Address - Phone:803-898-1555
Practice Address - Fax:803-898-2194
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-04
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024179774363LP0808X
SC28100363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health