Provider Demographics
NPI:1902067366
Name:JENNINGS, MARISA LEIGH (MD)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:LEIGH
Last Name:JENNINGS
Suffix:
Gender:
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:PO BOX 5010
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58702-5010
Mailing Address - Country:US
Mailing Address - Phone:701-418-8000
Mailing Address - Fax:
Practice Address - Street 1:1900 8TH AVE SE
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-4935
Practice Address - Country:US
Practice Address - Phone:701-857-5998
Practice Address - Fax:701-857-5022
Is Sole Proprietor?:No
Enumeration Date:2008-06-18
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND168282084P0800X
TXQ52002084P0800X
NDPT168282084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8FG967OtherBCBSTX
TX467526YLLWOtherMEDICARE
TX355635901Medicaid