Provider Demographics
NPI:1790809945
Name:JENNINGS, SHANE SETH
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:SETH
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 1:21453 HIGHWAY 126
Mailing Address - Street 2:
Mailing Address - City:NOTI
Mailing Address - State:OR
Mailing Address - Zip Code:97461-9729
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1790 W 11TH AVE STE 290
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97402-3759
Practice Address - Country:US
Practice Address - Phone:541-686-1262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health