Provider Demographics
NPI:1538217088
Name:MANNING, JENNIFER ANN (LICSW)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANN
Last Name:MANNING
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 1:120 LABREE AVE S
Mailing Address - Street 2:
Mailing Address - City:THIEF RIVER FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56701-2840
Mailing Address - Country:US
Mailing Address - Phone:218-683-4351
Mailing Address - Fax:
Practice Address - Street 1:120 LABREE AVE S
Practice Address - Street 2:
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701-2840
Practice Address - Country:US
Practice Address - Phone:218-683-4351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN162941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1538217088Medicaid
MN1538217088Medicaid