Provider Demographics
NPI:1255324190
Name:JENNINGS, LISA D (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:D
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-2757
Mailing Address - Country:US
Mailing Address - Phone:864-388-0301
Mailing Address - Fax:864-388-0648
Practice Address - Street 1:219A N MINE ST
Practice Address - Street 2:
Practice Address - City:MC CORMICK
Practice Address - State:SC
Practice Address - Zip Code:29835-8363
Practice Address - Country:US
Practice Address - Phone:864-852-3336
Practice Address - Fax:864-852-3339
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053559207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA166197103AMedicaid
GA166197103BMedicaid
GA166197103CMedicaid
GA166197103DMedicaid
GRP1619Medicare ID - Type Unspecified
GA166197103AMedicaid
GA166197103BMedicaid