Healthcare Provider Details

I. General information

NPI: 1043370570
Provider Name (Legal Business Name): SUSAN R JENNINGS PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24165 W IH 10 SUITE 130
SAN ANTONIO TX
78257-1159
US

IV. Provider business mailing address

24165 W IH 10 SUITE 130
SAN ANTONIO TX
78257-1159
US

V. Phone/Fax

Practice location:
  • Phone: 210-698-2202
  • Fax:
Mailing address:
  • Phone: 210-698-2202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number23352
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: