Provider Demographics
NPI:1457346561
Name:JENNINGS, TOM MCMAHON (ATC)
Entity Type:Individual
Prefix:MR
First Name:TOM
Middle Name:MCMAHON
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6959 WASHINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-1052
Mailing Address - Country:US
Mailing Address - Phone:317-691-0102
Mailing Address - Fax:
Practice Address - Street 1:820 W 122ND ST
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032-3828
Practice Address - Country:US
Practice Address - Phone:317-691-0102
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36000179A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer