MEDICARE: JOHNNETTA TINA JENNINGS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1154938124
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHNNETTA TINA JENNINGS

Provider Business Mailing Address
First Line	:	3540 N PENNSYLVANIA ST APT I
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46205-3991
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3520 WASHINGTON BLVD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46205-3719
Country	:	US
Telephone Number	:	260-450-2433
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/24/2020
Last Update Date	:	09/24/2020

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