Healthcare Provider Details

I. General information

NPI: 1063616795
Provider Name (Legal Business Name): DAVID ELLIS JENNINGS JR. MA, LPCC, LICDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 03/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8595 BEECHMONT AVENUE SUITE 303
CINCINNATI OH
45255
US

IV. Provider business mailing address

8595 BEECHMONT AVENUE SUITE 303
CINCINNATI OH
45255
US

V. Phone/Fax

Practice location:
  • Phone: 513-240-8558
  • Fax: 513-741-3589
Mailing address:
  • Phone: 513-240-8558
  • Fax: 513-741-3589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number882422-CS
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberE. 0016706
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberS.0016706
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: