Provider Demographics
NPI:1346914389
Name:JENNINGS, KERRY
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:SPARTA
Mailing Address - State:MI
Mailing Address - Zip Code:49345-1325
Mailing Address - Country:US
Mailing Address - Phone:616-887-0600
Mailing Address - Fax:616-887-5361
Practice Address - Street 1:11 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:SPARTA
Practice Address - State:MI
Practice Address - Zip Code:49345-1325
Practice Address - Country:US
Practice Address - Phone:616-887-0600
Practice Address - Fax:616-887-5361
Is Sole Proprietor?:No
Enumeration Date:2021-08-03
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5303035108183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician