Provider Demographics
NPI:1124844097
Name:JENNINGS, TYARA
Entity type:Individual
Prefix:
First Name:TYARA
Middle Name:
Last Name:JENNINGS
Suffix:
Gender:U
Credentials:
Other - Prefix:
Other - First Name:ROCKY
Other - Middle Name:
Other - Last Name:JENNINGS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:13553 ATLANTIC BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32225-4227
Mailing Address - Country:US
Mailing Address - Phone:904-420-7030
Mailing Address - Fax:
Practice Address - Street 1:13553 ATLANTIC BLVD STE 100
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32225-4227
Practice Address - Country:US
Practice Address - Phone:904-420-7030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician