Provider Demographics
NPI:1700850617
Name:JENNINGS, MICKEY JOSEPH (DC)
Entity Type:Individual
Prefix:
First Name:MICKEY
Middle Name:JOSEPH
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1152 CANAL BLVD
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-4534
Mailing Address - Country:US
Mailing Address - Phone:985-449-1000
Mailing Address - Fax:985-449-1200
Practice Address - Street 1:1152 CANAL BLVD
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-4534
Practice Address - Country:US
Practice Address - Phone:985-449-1000
Practice Address - Fax:985-449-1200
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA891111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA11940Medicare UPIN
LA5S719Medicare ID - Type UnspecifiedMEDICARE PROVIDER