Healthcare Provider Details

I. General information

NPI: 1104278720
Provider Name (Legal Business Name): BRYAN WILLIAM JENNINGS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2016
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL CENTER DR
LEBANON NH
03756-0001
US

IV. Provider business mailing address

1 MEDICAL CENTER DR
LEBANON NH
03756-0001
US

V. Phone/Fax

Practice location:
  • Phone: 603-650-8380
  • Fax: 603-640-1228
Mailing address:
  • Phone: 603-653-2075
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1504
License Number StateNH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: