Provider Demographics
NPI:1932451614
Name:JENNINGS, STEPHEN BRADLEY (LCSW)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:BRADLEY
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:816 E OLDHAM AVE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37917-5567
Mailing Address - Country:US
Mailing Address - Phone:865-300-0636
Mailing Address - Fax:865-525-2958
Practice Address - Street 1:816 E OLDHAM AVE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37917-5567
Practice Address - Country:US
Practice Address - Phone:865-300-0636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-05
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10820104100000X
104100000X
TN84921041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ081583Medicaid