Provider Demographics
NPI:1346538030
Name:MANESS, JESSICA B (LICSW)
Entity type:Individual
Prefix:
First Name:JESSICA
Middle Name:B
Last Name:MANESS
Suffix:
Gender:F
Credentials:LICSW
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 2077
Mailing Address - Street 2:
Mailing Address - City:GUALALA
Mailing Address - State:CA
Mailing Address - Zip Code:95445-2077
Mailing Address - Country:US
Mailing Address - Phone:701-690-2798
Mailing Address - Fax:707-703-5794
Practice Address - Street 1:45280 SEQUOIA RD
Practice Address - Street 2:
Practice Address - City:GUALALA
Practice Address - State:CA
Practice Address - Zip Code:95445-8664
Practice Address - Country:US
Practice Address - Phone:701-690-2798
Practice Address - Fax:701-872-3748
Is Sole Proprietor?:No
Enumeration Date:2011-07-14
Last Update Date:2024-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA706871041C0700X
ND45821041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1346538030OtherBLUE CROSS/BLUE SHIELD OF ND
ND19324Medicaid
ND74165Medicaid