Provider Demographics
NPI:1720296858
Name:JENNINGS, EUGENE LESLIE (MD)
Entity Type:Individual
Prefix:DR
First Name:EUGENE
Middle Name:LESLIE
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30-32 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:PA
Mailing Address - Zip Code:18407-2304
Mailing Address - Country:US
Mailing Address - Phone:570-242-2271
Mailing Address - Fax:
Practice Address - Street 1:30-32 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:PA
Practice Address - Zip Code:18407-2304
Practice Address - Country:US
Practice Address - Phone:570-242-2271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD069938L2084P0015X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMD069938LOtherLICENSE
PAMD069938LOtherLICENSE