Provider Demographics
NPI:1942549670
Name:JENNINGS, AMANDA (LSW)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 SILHAVY RD
Mailing Address - Street 2:STE 100
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-4461
Mailing Address - Country:US
Mailing Address - Phone:219-464-1234
Mailing Address - Fax:219-464-1235
Practice Address - Street 1:505 SILHAVY RD
Practice Address - Street 2:STE 100
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-4461
Practice Address - Country:US
Practice Address - Phone:219-464-1234
Practice Address - Fax:219-464-1235
Is Sole Proprietor?:No
Enumeration Date:2013-01-31
Last Update Date:2017-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN33006469A104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN33006469AMedicaid