Provider Demographics
NPI:1467036418
Name:TIANE JENNINGS, LICSW, PLLC
Entity Type:Organization
Organization Name:TIANE JENNINGS, LICSW, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOCIAL WORKER
Authorized Official - Prefix:MS
Authorized Official - First Name:TIANE
Authorized Official - Middle Name:HEATHER
Authorized Official - Last Name:JENNINGS
Authorized Official - Suffix:
Authorized Official - Credentials:LICSW
Authorized Official - Phone:602-402-9596
Mailing Address - Street 1:3 LEDGETREE RD
Mailing Address - Street 2:
Mailing Address - City:MEDFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:02052-2109
Mailing Address - Country:US
Mailing Address - Phone:602-402-9596
Mailing Address - Fax:
Practice Address - Street 1:3 LEDGETREE RD
Practice Address - Street 2:
Practice Address - City:MEDFIELD
Practice Address - State:MA
Practice Address - Zip Code:02052-2109
Practice Address - Country:US
Practice Address - Phone:602-402-9596
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-06
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health