Provider Demographics
NPI:1962701466
Name:MANOS, JENNIFER M (APRN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:MANOS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:M
Other - Last Name:MELVILLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3232 N NORTH HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-4005
Mailing Address - Country:US
Mailing Address - Phone:479-587-1700
Mailing Address - Fax:479-587-1366
Practice Address - Street 1:808 SOUTH 52ND STREET
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-8602
Practice Address - Country:US
Practice Address - Phone:479-936-9900
Practice Address - Fax:479-587-1366
Is Sole Proprietor?:No
Enumeration Date:2011-03-23
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA03532363LA2100X
ARATP-000356363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1962701466Medicaid
AR190323758Medicaid
OK200408730AMedicaid
4A151B823Medicare PIN
AR190323758Medicaid