MEDICARE: MMO JENNINGS, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA0600X	Adult Day Care Clinic/Center	7858	LA
2	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	60041	OTHER		BLUE CROSS
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578554853
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MMO JENNINGS, LLC

Provider Business Mailing Address
First Line	:	619 N MAIN ST
Second Line	:
City	:	JENNINGS
State	:	LA
Zip	:	70546-5347
Country	:	US
Telephone Number	:	337-824-4300
Fax Number	:	337-824-4315

Provider Business Practice Location Address
First Line	:	728 NORTH BOULEVARD
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70802-5724
Country	:	US
Telephone Number	:	225-293-6774
Fax Number	:	225-291-9229

Authorized Official
Title or Position	:	CEO
Name	:	MR. ROBERT L MILLER
Credential	:
Telephone Number	:	225-293-6774

Provider Enumeration Date	:	11/04/2005
Last Update Date	:	01/11/2011

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