Provider Demographics
NPI:1861495806
Name:JENNINGS, JEROME EDWIN (MD)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:EDWIN
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 1:1345 WESTGATE CENTER DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3040
Mailing Address - Country:US
Mailing Address - Phone:336-765-1571
Mailing Address - Fax:336-659-0425
Practice Address - Street 1:1345 WESTGATE CENTER DR
Practice Address - Street 2:SUITE B
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3040
Practice Address - Country:US
Practice Address - Phone:336-765-1571
Practice Address - Fax:336-659-0425
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2013-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17013207XS0114X, 207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0223770001OtherMEDICARE DME
NC45906OtherBCBSNC
NC8945906Medicaid
NC8945906Medicaid
NC201507Medicare PIN