Provider Demographics
NPI:1265497994
Name:JENNINGS, MARY V (PA)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:V
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11767 GAYVIEW DRIVE
Mailing Address - Street 2:
Mailing Address - City:LA MIRADA
Mailing Address - State:CA
Mailing Address - Zip Code:90638-1109
Mailing Address - Country:US
Mailing Address - Phone:562-944-6767
Mailing Address - Fax:
Practice Address - Street 1:11767 GAYVIEW DRIVE
Practice Address - Street 2:
Practice Address - City:LA MIRADA
Practice Address - State:CA
Practice Address - Zip Code:90638-1109
Practice Address - Country:US
Practice Address - Phone:562-944-6767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2012-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20759363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
R36544Medicare UPIN