Provider Demographics
NPI:1033300488
Name:JENNINGS, CASEY AMANDA (D O)
Entity Type:Individual
Prefix:DR
First Name:CASEY
Middle Name:AMANDA
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:D O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2305 GEORGIA ST
Mailing Address - Street 2:
Mailing Address - City:LOUISIANA
Mailing Address - State:MO
Mailing Address - Zip Code:63353-2559
Mailing Address - Country:US
Mailing Address - Phone:573-754-4584
Mailing Address - Fax:573-754-5280
Practice Address - Street 1:2305 GEORGIA ST
Practice Address - Street 2:
Practice Address - City:LOUISIANA
Practice Address - State:MO
Practice Address - Zip Code:63353-2559
Practice Address - Country:US
Practice Address - Phone:573-754-4584
Practice Address - Fax:573-754-5280
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-08
Last Update Date:2021-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007018507207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine