Provider Demographics
NPI:1730859661
Name:JENNINGS, JACOB
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:368 MEL MCDANIEL RD
Mailing Address - Street 2:
Mailing Address - City:RINGGOLD
Mailing Address - State:GA
Mailing Address - Zip Code:30736-5826
Mailing Address - Country:US
Mailing Address - Phone:423-762-6470
Mailing Address - Fax:
Practice Address - Street 1:315 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115-5030
Practice Address - Country:US
Practice Address - Phone:615-868-6503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-13
Last Update Date:2022-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN30945367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered