Provider Demographics
NPI:1073151767
Name:JENNINGS, CASSANDRA
Entity Type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:JENNINGS
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 1:2493 BARTH DR
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44505-2101
Mailing Address - Country:US
Mailing Address - Phone:330-774-8222
Mailing Address - Fax:
Practice Address - Street 1:2493 BARTH DR
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44505-2101
Practice Address - Country:US
Practice Address - Phone:330-774-8222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-13
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OHCDCA.182320101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2910854Medicaid