Provider Demographics
NPI:1891903365
Name:JENNINGS, JENNY VIDAL (RAS)
Entity Type:Individual
Prefix:MS
First Name:JENNY
Middle Name:VIDAL
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:RAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1124
Mailing Address - Street 2:
Mailing Address - City:BETHEL ISLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94511-1324
Mailing Address - Country:US
Mailing Address - Phone:510-374-3336
Mailing Address - Fax:510-374-3328
Practice Address - Street 1:2523 EL PORTAL DR
Practice Address - Street 2:
Practice Address - City:SAN PABLO
Practice Address - State:CA
Practice Address - Zip Code:94806
Practice Address - Country:US
Practice Address - Phone:510-374-3336
Practice Address - Fax:510-374-3328
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)