Healthcare Provider Details

I. General information

NPI: 1578478079
Provider Name (Legal Business Name): ANDREW JENNINGS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 BRANFORD PL
NEWARK NJ
07102-2711
US

IV. Provider business mailing address

31 FINLAY PL
NEWARK NJ
07106-1017
US

V. Phone/Fax

Practice location:
  • Phone: 973-623-7878
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberCPRS-50863
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: