Provider Demographics
NPI:1164588893
Name:JENNINGS, ANDRIA JILL (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ANDRIA
Middle Name:JILL
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:ANDRIA
Other - Middle Name:JILL
Other - Last Name:NISBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CSW
Mailing Address - Street 1:2437 W DANTE WAY
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85741-2606
Mailing Address - Country:US
Mailing Address - Phone:520-404-0296
Mailing Address - Fax:520-744-6212
Practice Address - Street 1:2262 W MAGEE RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85742-4329
Practice Address - Country:US
Practice Address - Phone:520-404-0296
Practice Address - Fax:520-744-6212
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-36171041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZLCSW-3617OtherLICENSED CLINICAL SW