Provider Demographics
NPI:1568435212
Name:MANN, JEFFREY L (DO)
Entity type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:L
Last Name:MANN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65 N HIGHWAY 25 W
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:KY
Mailing Address - Zip Code:40769-1540
Mailing Address - Country:US
Mailing Address - Phone:606-549-0123
Mailing Address - Fax:
Practice Address - Street 1:65 N HIGHWAY 25 W
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:KY
Practice Address - Zip Code:40769-1540
Practice Address - Country:US
Practice Address - Phone:606-549-0123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYC2299208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN194793OtherBLUE CROSS BLUE SHIELD
TN3067653Medicaid
TN4073350OtherAETNA
TN113085OtherBHP (UNISON)
TN12140OtherTLC
TN5440810Medicaid
TN4073350OtherAETNA
TN113085OtherBHP (UNISON)