Provider Demographics
NPI:1578554853
Name:MMO JENNINGS, LLC
Entity Type:Organization
Organization Name:MMO JENNINGS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:L
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-293-6774
Mailing Address - Street 1:619 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JENNINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70546-5347
Mailing Address - Country:US
Mailing Address - Phone:337-824-4300
Mailing Address - Fax:337-824-4315
Practice Address - Street 1:728 NORTH BOULEVARD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70802-5724
Practice Address - Country:US
Practice Address - Phone:225-293-6774
Practice Address - Fax:225-291-9229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-04
Last Update Date:2011-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7858261QA0600X
261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
60041OtherBLUE CROSS
LA1428400Medicaid
5C425Medicare ID - Type UnspecifiedMEDICARE B
194664Medicare ID - Type Unspecified