Provider Demographics
NPI:1871886820
Name:JENNINGS, TARA (LMT)
Entity type:Individual
Prefix:MISS
First Name:TARA
Middle Name:
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 W AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-2767
Mailing Address - Country:US
Mailing Address - Phone:541-910-8459
Mailing Address - Fax:
Practice Address - Street 1:207 FIR ST
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-2626
Practice Address - Country:US
Practice Address - Phone:541-624-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-24
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR13316174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist