Provider Demographics
NPI:1336481514
Name:JENNINGS, KYLE D (BS)
Entity Type:Individual
Prefix:
First Name:KYLE
Middle Name:D
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:702 W CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-2814
Mailing Address - Country:US
Mailing Address - Phone:309-557-1472
Mailing Address - Fax:
Practice Address - Street 1:702 W CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-2814
Practice Address - Country:US
Practice Address - Phone:309-557-1472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-26
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)