Provider Demographics
NPI:1235406661
Name:JENNINGS, BEAU (BA)
Entity Type:Individual
Prefix:MR
First Name:BEAU
Middle Name:
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 TREMONT ST
Mailing Address - Street 2:APT 3
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37405-4190
Mailing Address - Country:US
Mailing Address - Phone:325-660-2998
Mailing Address - Fax:
Practice Address - Street 1:6110 SHALLOWFORD RD
Practice Address - Street 2:SUITE B
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-1894
Practice Address - Country:US
Practice Address - Phone:423-509-4128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-30
Last Update Date:2011-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator