Provider Demographics
NPI:1336196898
Name:JENNINGS, GLENN E (MD)
Entity Type:Individual
Prefix:MR
First Name:GLENN
Middle Name:E
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:445 DOLLEY MADISON RD STE 410
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-5167
Mailing Address - Country:US
Mailing Address - Phone:336-292-1510
Mailing Address - Fax:336-292-0679
Practice Address - Street 1:445 DOLLEY MADISON RD STE 410
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27410-5167
Practice Address - Country:US
Practice Address - Phone:336-292-1510
Practice Address - Fax:336-292-0679
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2004010762084P0800X, 2084P0804X
NC2004-010762084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1371FOtherBCBS NC
NC343712OtherMANAGED HEALTH NETWORK
NC891371FMedicaid
NCD6763OtherMEDCOST
NC7654624OtherAETNA
NC343712OtherMANAGED HEALTH NETWORK
NCNCS292D205Medicare UPIN
NC891371FMedicaid