Provider Demographics
NPI:1801874714
Name:JENNINGS, KEVIN T (OD)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:T
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2743 MT PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:IA
Mailing Address - Zip Code:52601-2137
Mailing Address - Country:US
Mailing Address - Phone:319-754-2020
Mailing Address - Fax:319-754-2299
Practice Address - Street 1:2743 MT PLEASANT ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52601-2137
Practice Address - Country:US
Practice Address - Phone:319-754-2020
Practice Address - Fax:319-754-2299
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAIA1897152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1058602Medicaid
IA410012433OtherRAILROAD MEDICARE
IA1058602Medicaid
IA06546Medicare PIN