Provider Demographics
NPI:1487707006
Name:JENNINGS, VALDEA DELANO (EDD)
Entity type:Individual
Prefix:DR
First Name:VALDEA
Middle Name:DELANO
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:EDD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 W MOUNT AIRY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-2941
Mailing Address - Country:US
Mailing Address - Phone:215-248-5228
Mailing Address - Fax:
Practice Address - Street 1:333 W MOUNT AIRY AVE
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19119-2941
Practice Address - Country:US
Practice Address - Phone:215-248-5228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS000363L103TC2200X, 103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Not Answered103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0062849000Medicare UPIN
PA7200026Medicare UPIN