1164588893 NPI number — MS. ANDRIA JILL JENNINGS LCSW

Table of content: MS. ANDRIA JILL JENNINGS LCSW (NPI 1164588893)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164588893 NPI number — MS. ANDRIA JILL JENNINGS LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JENNINGS
Provider First Name:
ANDRIA
Provider Middle Name:
JILL
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
NISBERG
Provider Other First Name:
ANDRIA
Provider Other Middle Name:
JILL
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
CSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1164588893
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2437 W DANTE WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUCSON
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85741-2606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
520-404-0296
Provider Business Mailing Address Fax Number:
520-744-6212

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2262 W MAGEE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUCSON
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85742-4329
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
520-404-0296
Provider Business Practice Location Address Fax Number:
520-744-6212
Provider Enumeration Date:
12/28/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  LCSW-3617 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: LCSW-3617 . This is a "LICENSED CLINICAL SW" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".