Provider Demographics
NPI:1578651113
Name:JENNINGS, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1909
Mailing Address - Street 2:486 ANDREWS AVENUE
Mailing Address - City:OZARK
Mailing Address - State:AL
Mailing Address - Zip Code:36361-1909
Mailing Address - Country:US
Mailing Address - Phone:334-774-5952
Mailing Address - Fax:334-445-9006
Practice Address - Street 1:486 ANDREWS AVE
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:AL
Practice Address - Zip Code:36360-3806
Practice Address - Country:US
Practice Address - Phone:334-774-5952
Practice Address - Fax:334-445-9006
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2022-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL50801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009957325Medicaid
AL515-05271OtherBCBS OF AL PROVIDER ID