Provider Demographics
NPI:1801209242
Name:JENNINGS, CASEY
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 FLAGG ST
Mailing Address - Street 2:
Mailing Address - City:BOYLSTON
Mailing Address - State:MA
Mailing Address - Zip Code:01505-1953
Mailing Address - Country:US
Mailing Address - Phone:774-262-3392
Mailing Address - Fax:
Practice Address - Street 1:548 PARK AVE STE B
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01603-2537
Practice Address - Country:US
Practice Address - Phone:774-823-1500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-03
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program