Provider Demographics
NPI:1801394531
Name:JENNINGS, DIANA LINDA
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:LINDA
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3925 N.MARTIN LUTHER KING BLVD.#207
Mailing Address - Street 2:
Mailing Address - City:N. LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032
Mailing Address - Country:US
Mailing Address - Phone:702-684-7757
Mailing Address - Fax:702-684-7381
Practice Address - Street 1:3925 MARTIN LUTHER KING BLVD
Practice Address - Street 2:207
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032
Practice Address - Country:US
Practice Address - Phone:702-684-7757
Practice Address - Fax:702-684-7391
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-29
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health