Provider Demographics
NPI:1578387221
Name:JENNINGS, CHRISTINA RENEE
Entity type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:RENEE
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15621 ORCHID DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-1334
Mailing Address - Country:US
Mailing Address - Phone:219-742-1028
Mailing Address - Fax:
Practice Address - Street 1:1016 W JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60607-2914
Practice Address - Country:US
Practice Address - Phone:773-466-1555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-11
Last Update Date:2024-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-23-306282106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty