Provider Demographics
NPI:1922051309
Name:JENNINGS, HAROLD L (OD)
Entity Type:Individual
Prefix:
First Name:HAROLD
Middle Name:L
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:OD
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 367
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27323-0367
Mailing Address - Country:US
Mailing Address - Phone:336-342-3159
Mailing Address - Fax:336-349-2277
Practice Address - Street 1:1203 NORTHUP ST
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-5511
Practice Address - Country:US
Practice Address - Phone:336-342-3159
Practice Address - Fax:336-349-2277
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0797152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8909452Medicaid
NCT64710Medicare UPIN
NC246151Medicare ID - Type Unspecified
NC8909452Medicaid