Healthcare Provider Details

I. General information

NPI: 1790186708
Provider Name (Legal Business Name): CHARLES ANTHONY JENNINGS RN, NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2014
Last Update Date: 09/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1550 HOTEL CIR N SUITE 450
SAN DIEGO CA
92108-2901
US

IV. Provider business mailing address

PO BOX 609001
SAN DIEGO CA
92160-9001
US

V. Phone/Fax

Practice location:
  • Phone: 619-692-1581
  • Fax: 619-692-1588
Mailing address:
  • Phone: 619-528-4600
  • Fax: 619-528-4625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95000764
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: