Provider Demographics
NPI:1104302629
Name:JENNINGS, CHAD ALLEN (MS,OTR)
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:ALLEN
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:MS,OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2226 SHADY PINES RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75501-8970
Mailing Address - Country:US
Mailing Address - Phone:903-748-3097
Mailing Address - Fax:
Practice Address - Street 1:5610 RICHMOND RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-0500
Practice Address - Country:US
Practice Address - Phone:903-791-9355
Practice Address - Fax:855-218-5819
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-18
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX110599225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist