Provider Demographics
NPI:1114145687
Name:PENNINGTON, JENNIFER ANNE (DO)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ANNE
Last Name:PENNINGTON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:ANNE
Other - Last Name:ANDREASCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:4630 VISTULA RD
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-4000
Practice Address - Country:US
Practice Address - Phone:574-647-1900
Practice Address - Fax:574-254-7222
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02003207A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000533533OtherBCBS BMG SCHWARTZ-WIEKAMP
IN200874950Medicaid
INP00734479OtherRR MEDICARE
IN200874950Medicaid
IN000000533533OtherBCBS BMG SCHWARTZ-WIEKAMP
IN000000533533OtherBCBS BMG SCHWARTZ-WIEKAMP
INM400068866Medicare PIN
IN000000758919OtherBCBS BMG E BLAIR WARNER
IN236040G2Medicare PIN