Provider Demographics
NPI:1700429057
Name:JENNINGS, ALICIA RENEE (CSA)
Entity Type:Individual
Prefix:MS
First Name:ALICIA
Middle Name:RENEE
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4624 E SANDS DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-6862
Mailing Address - Country:US
Mailing Address - Phone:518-836-1672
Mailing Address - Fax:
Practice Address - Street 1:4624 E SANDS DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-6862
Practice Address - Country:US
Practice Address - Phone:518-836-1672
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-18
Last Update Date:2019-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Single Specialty