1972860369 NPI number — LESAJEAN M. JENNINGS, PSY.D.

Table of content: (NPI 1972860369)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972860369 NPI number — LESAJEAN M. JENNINGS, PSY.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LESAJEAN M. JENNINGS, PSY.D.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972860369
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/23/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1319 LIVE OAK ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77003-4408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-225-2280
Provider Business Mailing Address Fax Number:
713-225-5787

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1319 LIVE OAK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77003-4408
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-225-2280
Provider Business Practice Location Address Fax Number:
713-225-5787
Provider Enumeration Date:
04/23/2012

Additional Information

Authorized Official

Authorized Official Last Name:
JENNINGS
Authorized Official First Name:
LESAJEAN
Authorized Official Middle Name:
MCDONALD
Authorized Official Title or Position:
LICENSED PSYCHOLOGIST / OWNER
Authorized Official Telephone Number:
713-225-2280

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  25562 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 10020773 . This is a "AMERIGROUP" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 107094 . This is a "SUPERIOR" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 135153 . This is a "VALUE OPTIONS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 0062BT . This is a "BLUE CROSS / BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 167799 . This is a "COMPSYCH" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: JENNI-0006 . This is a "COMPCARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 1136236-01 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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