Healthcare Provider Details

I. General information

NPI: 1356315246
Provider Name (Legal Business Name): MARK JENNINGS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PEDIATRIC NEUROLOGY 515 NE GLEN OAK #308
PEORIA IL
61603
US

IV. Provider business mailing address

1 ILLINI DR
PEORIA IL
61605-2576
US

V. Phone/Fax

Practice location:
  • Phone: 309-624-9844
  • Fax:
Mailing address:
  • Phone: 309-671-8503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: