Provider Demographics
NPI:1104596295
Name:JENNINGS, JENELLE EYSE
Entity type:Individual
Prefix:
First Name:JENELLE
Middle Name:EYSE
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 1:1155 GRAND CENTRAL PKWY BLDG F
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-3185
Mailing Address - Country:US
Mailing Address - Phone:936-315-3811
Mailing Address - Fax:
Practice Address - Street 1:1155 GRAND CENTRAL PKWY BLDG F
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-3185
Practice Address - Country:US
Practice Address - Phone:936-315-3787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-20
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
TX6282103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician