Provider Demographics
NPI:1588755102
Name:JENNINGS, LIA CHRISTINE
Entity type:Individual
Prefix:
First Name:LIA
Middle Name:CHRISTINE
Last Name:JENNINGS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3875 TELEGRAPH RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-3419
Mailing Address - Country:US
Mailing Address - Phone:805-477-0909
Mailing Address - Fax:
Practice Address - Street 1:3875 TELEGRAPH RD
Practice Address - Street 2:SUITE C
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-3419
Practice Address - Country:US
Practice Address - Phone:805-477-0909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17114225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT17114AMedicare ID - Type UnspecifiedMEDICARE PROVIDER-PTPP