Provider Demographics
NPI:1922738202
Name:JENNINGS, SHAVON MONIQUE
Entity Type:Individual
Prefix:
First Name:SHAVON
Middle Name:MONIQUE
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 1:3618 CUMMINGS RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44118-2627
Mailing Address - Country:US
Mailing Address - Phone:216-512-3691
Mailing Address - Fax:
Practice Address - Street 1:3047 E 121ST ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44120-2965
Practice Address - Country:US
Practice Address - Phone:216-203-7009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-10
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH06102022Medicaid