Healthcare Provider Details

I. General information

NPI: 1518965201
Provider Name (Legal Business Name): JOHN MARK JENNINGS LCSW, BCD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 11/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

213 W OHIO ST
MORGANTOWN KY
42261-8436
US

IV. Provider business mailing address

PO BOX 1205
MORGANTOWN KY
42261-1205
US

V. Phone/Fax

Practice location:
  • Phone: 270-526-2228
  • Fax: 270-526-2218
Mailing address:
  • Phone: 270-526-2228
  • Fax: 270-526-2218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number1031
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: