Provider Demographics
NPI:1790796712
Name:JENNINGS, JACKIE JEAN (RPSGT)
Entity Type:Individual
Prefix:MRS
First Name:JACKIE
Middle Name:JEAN
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:RPSGT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:183 GRIFFIN SHOALS RD
Mailing Address - Street 2:
Mailing Address - City:DADEVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36853-3106
Mailing Address - Country:US
Mailing Address - Phone:256-825-9424
Mailing Address - Fax:256-825-2078
Practice Address - Street 1:183 GRIFFIN SHOALS RD
Practice Address - Street 2:
Practice Address - City:DADEVILLE
Practice Address - State:AL
Practice Address - Zip Code:36853-3106
Practice Address - Country:US
Practice Address - Phone:256-825-9424
Practice Address - Fax:256-825-2078
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL729247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other