Basic Information
| Provider Information | |||||||||
| NPI: | 1982694485 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEISEL-MANGANO | ||||||||
| FirstName: | JENNIFER | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 129 5TH ST SE | ||||||||
| Address2: | |||||||||
| City: | BARBERTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442034204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306310010 | ||||||||
| FaxNumber: | 3306310011 | ||||||||
| Practice Location | |||||||||
| Address1: | 129 5TH ST SE | ||||||||
| Address2: | |||||||||
| City: | BARBERTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442034204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3306310010 | ||||||||
| FaxNumber: | 3306310011 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2005 | ||||||||
| LastUpdateDate: | 03/10/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT05017 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 2251S0007X | PT05017 | OH | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports | 2251X0800X | PT05017 | OH | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
ID Information
| ID | Type | State | Issuer | Description | PT05017 | 01 | OH | OT PT ATC BOARD | OTHER |