Provider Demographics
NPI:1437652567
Name:JENNINGS, ANDREA S (PA-C, RD)
Entity type:Individual
Prefix:
First Name:ANDREA
Middle Name:S
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:PA-C, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42420-2783
Mailing Address - Country:US
Mailing Address - Phone:270-631-2412
Mailing Address - Fax:270-631-2421
Practice Address - Street 1:110 2ND ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-3136
Practice Address - Country:US
Practice Address - Phone:270-631-2412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-15
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA284363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty