Provider Demographics
NPI:1508046723
Name:JENNINGS, TARA (NP)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:3400 SPRUCE ST
Mailing Address - Street 2:2 RAVDIN
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19104
Mailing Address - Country:US
Mailing Address - Phone:215-662-3606
Mailing Address - Fax:215-349-5579
Practice Address - Street 1:55 FRUIT ST
Practice Address - Street 2:ACC 735
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2621
Practice Address - Country:US
Practice Address - Phone:617-726-3311
Practice Address - Fax:617-726-9250
Is Sole Proprietor?:No
Enumeration Date:2007-11-05
Last Update Date:2020-10-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PASP022480363L00000X
MA262759363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health