Provider Demographics
NPI:1639316797
Name:JENNINGS, M SHANE (MD)
Entity type:Individual
Prefix:
First Name:M
Middle Name:SHANE
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:SHANE
Other - Last Name:JENNINGS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:4301 W MARKHAM ST # 783
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-7199
Mailing Address - Country:US
Mailing Address - Phone:501-686-8000
Mailing Address - Fax:501-526-5148
Practice Address - Street 1:4301 W MARKHAM ST # 584
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7199
Practice Address - Country:US
Practice Address - Phone:501-686-8000
Practice Address - Fax:501-526-5148
Is Sole Proprietor?:No
Enumeration Date:2009-01-12
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY266197207P00000X
TXR0031207P00000X
KS04-46598207P00000X
ARE-16517207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX371627601Medicaid
NY03486688Medicaid
TX371627602OtherCSHCN
TX371627601Medicaid