Provider Demographics
NPI:1396503553
Name:JENNINGS, JAYE RICHARD
Entity type:Individual
Prefix:
First Name:JAYE
Middle Name:RICHARD
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 ZARTHAN AVE S UNIT 101
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1451
Mailing Address - Country:US
Mailing Address - Phone:507-696-3129
Mailing Address - Fax:
Practice Address - Street 1:7505 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:MN
Practice Address - Zip Code:55427-4501
Practice Address - Country:US
Practice Address - Phone:763-450-6900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN105391225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist