Provider Demographics
NPI:1639248115
Name:DAVID C JENNINGS PC
Entity Type:Organization
Organization Name:DAVID C JENNINGS PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:C
Authorized Official - Last Name:JENNINGS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:815-718-0020
Mailing Address - Street 1:201 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:MORRISON
Mailing Address - State:IL
Mailing Address - Zip Code:61270-2854
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 E MARKET ST
Practice Address - Street 2:
Practice Address - City:MORRISON
Practice Address - State:IL
Practice Address - Zip Code:61270-2854
Practice Address - Country:US
Practice Address - Phone:815-718-0020
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2014-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-006739152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00057517OtherRAILROAD MEDICARE
IL060-002897OtherCORPORATION LICENSE NUMBE
IL9826676OtherBLUE CROSS BLUE SHIELD
ILD 5228-360-4OtherCORPORATION FILE NUMBER
IL0241380001Medicare NSC
ILD 5228-360-4OtherCORPORATION FILE NUMBER