Provider Demographics
NPI:1093899338
Name:JENNINGS, JEFFREY L (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:L
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:691 S WENAS
Mailing Address - Street 2:
Mailing Address - City:SELAH
Mailing Address - State:WA
Mailing Address - Zip Code:98942
Mailing Address - Country:US
Mailing Address - Phone:509-480-8258
Mailing Address - Fax:
Practice Address - Street 1:691 S WENAS
Practice Address - Street 2:
Practice Address - City:SELAH
Practice Address - State:WA
Practice Address - Zip Code:98942
Practice Address - Country:US
Practice Address - Phone:509-480-8258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000319852084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8157299Medicaid
190436Medicare ID - Type Unspecified
WA8157299Medicaid