Provider Demographics
NPI:1225133606
Name:JENNISCH, CHARLES SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:SCOTT
Last Name:JENNISCH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:C
Other - Middle Name:SCOTT
Other - Last Name:JENNISCH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:6921 HICKMAN RD STE 2327
Mailing Address - Street 2:
Mailing Address - City:URBANDALE
Mailing Address - State:IA
Mailing Address - Zip Code:50322-4805
Mailing Address - Country:US
Mailing Address - Phone:515-270-2242
Mailing Address - Fax:
Practice Address - Street 1:6921 HICKMAN RD STE 2327
Practice Address - Street 2:
Practice Address - City:URBANDALE
Practice Address - State:IA
Practice Address - Zip Code:50322-4805
Practice Address - Country:US
Practice Address - Phone:515-270-2242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA325332084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1213199Medicaid
IA21492OtherWELLMARK
IAG87941Medicare UPIN
IA21492OtherWELLMARK