Provider Demographics
NPI:1023569456
Name:JENNINGS, DILLON
Entity Type:Individual
Prefix:
First Name:DILLON
Middle Name:
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10608 SERENBE LN
Mailing Address - Street 2:
Mailing Address - City:PALMETTO
Mailing Address - State:GA
Mailing Address - Zip Code:30268-2287
Mailing Address - Country:US
Mailing Address - Phone:405-570-1523
Mailing Address - Fax:
Practice Address - Street 1:1004 BANKHEAD HWY
Practice Address - Street 2:SUITE A5
Practice Address - City:CARROLLTON
Practice Address - State:GA
Practice Address - Zip Code:30117-1852
Practice Address - Country:US
Practice Address - Phone:770-834-5609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-20
Last Update Date:2016-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPTA003676225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant