MEDICARE: MS. ANDRIA JILL JENNINGS LCSW

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	1041C0700X	Clinical Social Worker	LCSW-3617	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LCSW-3617	OTHER	AZ	LICENSED CLINICAL SW

General Provider Information

NPI Number	:	1164588893
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ANDRIA JILL JENNINGS LCSW

Provider Business Mailing Address
First Line	:	2437 W DANTE WAY
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85741-2606
Country	:	US
Telephone Number	:	520-404-0296
Fax Number	:	520-744-6212

Provider Business Practice Location Address
First Line	:	2262 W MAGEE RD
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85742-4329
Country	:	US
Telephone Number	:	520-404-0296
Fax Number	:	520-744-6212

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

Provider Enumeration Date	:	12/28/2006
Last Update Date	:	07/08/2007

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