Basic Information
| Provider Information | |||||||||
| NPI: | 1437508710 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MANNING | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | CODY | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | M.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6110 SHALLOWFORD RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374211894 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 6110 SHALLOWFORD RD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374211894 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234991031 | ||||||||
| FaxNumber: | 4232966384 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2016 | ||||||||
| LastUpdateDate: | 06/08/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 1255 | TN | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.