Provider Demographics
NPI:1497836209
Name:JENNINGS, JANNA LYN (MD)
Entity Type:Individual
Prefix:
First Name:JANNA
Middle Name:LYN
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 102A
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72015-3729
Mailing Address - Country:US
Mailing Address - Phone:501-315-1222
Mailing Address - Fax:501-315-1241
Practice Address - Street 1:5 MEDICAL PARK DR
Practice Address - Street 2:SUITE 102A
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-3729
Practice Address - Country:US
Practice Address - Phone:501-315-1222
Practice Address - Fax:501-315-1222
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE5062208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR162043001Medicaid
ART2006-171OtherSTATE LICENSE