Healthcare Provider Details

I. General information

NPI: 1790698009
Provider Name (Legal Business Name): DAWN S JENNINGS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2026
Last Update Date: 09/26/2026
Certification Date: 09/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2420 VIRIDIAN DR
SOUTH BEND IN
46628-4396
US

IV. Provider business mailing address

806 OBRIEN ST
SOUTH BEND IN
46628-2518
US

V. Phone/Fax

Practice location:
  • Phone: 574-314-0492
  • Fax:
Mailing address:
  • Phone: 574-314-0492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number33013228A
License Number State
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number99135492A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: