=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265311294
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DYLAN JENNINGS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/02/2025
-----------------------------------------------------
Last Update Date | 09/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 629 OAKLAND AVE
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94611-4567
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-658-9480
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 929 CLARKSON CT
-----------------------------------------------------
City | CONCORD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94518-3466
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 373H00000X
-----------------------------------------------------
Taxonomy Name | Day Training/Habilitation Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------