Healthcare Provider Details

I. General information

NPI: 1235651522
Provider Name (Legal Business Name): CRAIG ALEXANDER JENNINGS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2017
Last Update Date: 03/28/2023
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1110 7TH AVE
CUMBERLAND WI
54829-9138
US

IV. Provider business mailing address

1110 7TH AVE
CUMBERLAND WI
54829-9138
US

V. Phone/Fax

Practice location:
  • Phone: 715-822-7200
  • Fax:
Mailing address:
  • Phone: 715-822-7200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number72848
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: