Provider Demographics
NPI:1043370570
Name:JENNINGS, SUSAN R (PHD)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:R
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24165 W IH 10
Mailing Address - Street 2:SUITE 130
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78257-1159
Mailing Address - Country:US
Mailing Address - Phone:210-698-2202
Mailing Address - Fax:
Practice Address - Street 1:24165 W IH 10
Practice Address - Street 2:SUITE 130
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78257-1159
Practice Address - Country:US
Practice Address - Phone:210-698-2202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23352103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00DX59Medicaid
TX00DX59Medicare UPIN