Provider Demographics
NPI:1669150223
Name:JENNINGS, JENNIFER LYNN I (LPN)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:JENNINGS
Suffix:I
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4646 JOHN R ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-1916
Mailing Address - Country:US
Mailing Address - Phone:734-626-3894
Mailing Address - Fax:
Practice Address - Street 1:4646 JOHN R
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-576-3966
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703083772207RA0401X, 164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine