Healthcare Provider Details

I. General information

NPI: 1770613770
Provider Name (Legal Business Name): LARRY E JENNINGS MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3235 E MICHIGAN AVE
JACKSON MI
49202-3971
US

IV. Provider business mailing address

3235 E MICHIGAN AVE
JACKSON MI
49202-3971
US

V. Phone/Fax

Practice location:
  • Phone: 517-787-3280
  • Fax: 517-787-1612
Mailing address:
  • Phone: 517-787-3280
  • Fax: 517-787-1612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5301025270
License Number StateMI

VIII. Authorized Official

Name: SANDRA HULL
Title or Position: OFFICE MANAGER
Credential:
Phone: 517-787-3280