Provider Demographics
NPI:1225162258
Name:JENNINGS, RICKY DEWAYNE (DC)
Entity Type:Individual
Prefix:DR
First Name:RICKY
Middle Name:DEWAYNE
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 GLEN CT
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75062-6637
Mailing Address - Country:US
Mailing Address - Phone:972-258-1983
Mailing Address - Fax:
Practice Address - Street 1:3401 W AIRPORT FWY
Practice Address - Street 2:SUITE 101
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-5924
Practice Address - Country:US
Practice Address - Phone:214-334-0125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-14
Last Update Date:2008-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8360111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00874NMedicare PIN