Provider Demographics
NPI:1043923147
Name:JENNINGS, KELLY (MH 21536)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:MH 21536
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 TYRINGHAM RD
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726
Mailing Address - Country:US
Mailing Address - Phone:352-354-4004
Mailing Address - Fax:
Practice Address - Street 1:858 S DUNCAN DR
Practice Address - Street 2:
Practice Address - City:TAVARES
Practice Address - State:FL
Practice Address - Zip Code:32778-4044
Practice Address - Country:US
Practice Address - Phone:352-609-5103
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-04
Last Update Date:2023-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH21536101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health