Provider Demographics
NPI:1639316797
Name:JENNINGS, M. SHANE (MD)
Entity Type:Individual
Prefix:
First Name:M.
Middle Name:SHANE
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 CAMBRIDGE STREET MAILBOX 1019
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66160-0001
Mailing Address - Country:US
Mailing Address - Phone:913-588-6504
Mailing Address - Fax:
Practice Address - Street 1:4000 CAMBRIDGE ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160-4402
Practice Address - Country:US
Practice Address - Phone:913-588-6504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-12
Last Update Date:2022-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY266197207P00000X
TXR0031207P00000X
390200000X
KS04-46598207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03486688Medicaid
TX371627601Medicaid
TX371627602OtherCSHCN
TX371627601Medicaid