Provider Demographics
NPI:1427374552
Name:JENNINGS, DIMETA
Entity Type:Individual
Prefix:
First Name:DIMETA
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 1:26241 LAKE SHORE BLVD
Mailing Address - Street 2:APT. 155
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44132-1140
Mailing Address - Country:US
Mailing Address - Phone:216-835-1694
Mailing Address - Fax:
Practice Address - Street 1:26241 LAKE SHORE BLVD
Practice Address - Street 2:APT. 155
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44132-1140
Practice Address - Country:US
Practice Address - Phone:216-835-1694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-14
Last Update Date:2010-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN130214164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse