Provider Demographics
NPI:1225249949
Name:JENNINGS, JOHN M (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:M
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 N ALVERNON WAY
Mailing Address - Street 2:SUITE 250
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85711-1843
Mailing Address - Country:US
Mailing Address - Phone:520-647-8854
Mailing Address - Fax:520-647-8851
Practice Address - Street 1:822 W 4TH ST
Practice Address - Street 2:
Practice Address - City:LEADVILLE
Practice Address - State:CO
Practice Address - Zip Code:80461-3861
Practice Address - Country:US
Practice Address - Phone:719-486-0230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA1732363A00000X
AZ2747363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant