Provider Demographics
NPI:1871106518
Name:MANN, JESSE LUKE (PTA)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:LUKE
Last Name:MANN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 BINFORD ST APT 302
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82072-5380
Mailing Address - Country:US
Mailing Address - Phone:307-761-1661
Mailing Address - Fax:
Practice Address - Street 1:503 S 18TH ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-4303
Practice Address - Country:US
Practice Address - Phone:307-742-3728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYPTA-1022225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant