Provider Demographics
NPI:1871903955
Name:MANELICK, JORDAN
Entity type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:MANELICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 KNIK GOOSE BAY RD
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654
Mailing Address - Country:US
Mailing Address - Phone:907-631-7800
Mailing Address - Fax:
Practice Address - Street 1:1001 S KNIK GOOSE BAY RD
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8083
Practice Address - Country:US
Practice Address - Phone:907-631-7800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant