Provider Demographics
NPI:1265993091
Name:MANNING, JACKIE RENEE (ARNP)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:RENEE
Last Name:MANNING
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:191 E OHIO AVE
Mailing Address - Street 2:
Mailing Address - City:MACCLENNY
Mailing Address - State:FL
Mailing Address - Zip Code:32063-2137
Mailing Address - Country:US
Mailing Address - Phone:904-545-0509
Mailing Address - Fax:
Practice Address - Street 1:789 W DUVAL ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-3811
Practice Address - Country:US
Practice Address - Phone:386-755-5044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-26
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11001650363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily