Provider Demographics
NPI:1225108475
Name:JENNINGS, HENRY ALVIN JR
Entity Type:Individual
Prefix:MR
First Name:HENRY
Middle Name:ALVIN
Last Name:JENNINGS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10683 MAGNOLIA AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-1893
Mailing Address - Country:US
Mailing Address - Phone:951-352-2029
Mailing Address - Fax:951-352-2549
Practice Address - Street 1:10683 MAGNOLIA AVE
Practice Address - Street 2:SUITE A
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-1893
Practice Address - Country:US
Practice Address - Phone:951-352-2029
Practice Address - Fax:951-352-2549
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACPO-02544222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Not Answered224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGXC000030Medicaid
CAGXC000030Medicaid