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Jerome Edwin Jennings

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NPI Number Detailed Information

Provider Information:

Name: Jerome Edwin Jennings
Gender: M
Provider License Number If Given: 17013

NPI Information:

NPI: 1861495806
Entity Type
(Individual or Organization):
1-ind
Enumeration Date: 5/23/2005

Last Update Date: 2/18/2013

Provider Business Mailing Address:

Address: 1345 WESTGATE CENTER DR SUITE B
Winston Salem, NC 27103
Phone Number: 3367651571
Fax Number: 3366590425

Provider Business Practice Location Address:

Address: 1345 WESTGATE CENTER DR SUITE B
Winston Salem, NC 27103
Phone Number: 3367651571
Fax Number: 3366590425

Provider Taxonomy:

Primary: 207X00000X
Secondary (if any): 207XS0114X
State: NC

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