Provider Demographics
NPI:1396044038
Name:JENNINGS, BRADLEY TAYLOR (DPM)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:TAYLOR
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:248 NILES CORTLAND RD NE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-1938
Mailing Address - Country:US
Mailing Address - Phone:330-856-1700
Mailing Address - Fax:330-856-5375
Practice Address - Street 1:248 NILES CORTLAND RD NE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-1938
Practice Address - Country:US
Practice Address - Phone:330-856-1700
Practice Address - Fax:330-856-5375
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-21
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36.003624213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery