Provider Demographics
NPI:1083313977
Name:JENNINGS, FATIMA
Entity Type:Individual
Prefix:
First Name:FATIMA
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 1:509 HIGHLAND DR
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23075-1721
Mailing Address - Country:US
Mailing Address - Phone:804-807-1311
Mailing Address - Fax:
Practice Address - Street 1:509 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23075-1721
Practice Address - Country:US
Practice Address - Phone:804-661-9239
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-28
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA101YM0800XMedicaid
VA921841153Medicaid