Provider Demographics
NPI:1366558777
Name:JENNINGS, BRUCE PHILLIP (PH D)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:PHILLIP
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2712
Mailing Address - Street 2:300 FOXCROFT AVE SUITE 306
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25402-2712
Mailing Address - Country:US
Mailing Address - Phone:304-267-1663
Mailing Address - Fax:304-267-1663
Practice Address - Street 1:300 FOXCROFT AVE
Practice Address - Street 2:SUITE 306
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401
Practice Address - Country:US
Practice Address - Phone:304-267-1663
Practice Address - Fax:304-267-1663
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2012-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV291103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
JECP14701Medicare ID - Type Unspecified