Basic Information
| Provider Information | |||||||||
| NPI: | 1225051824 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JENKINS | ||||||||
| FirstName: | SERREDA | ||||||||
| MiddleName: | KING | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MSW, LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 204 S BREVARD ST | ||||||||
| Address2: | P.O. BOX 806 | ||||||||
| City: | SELMA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275762404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199654009 | ||||||||
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| Practice Location | |||||||||
| Address1: | 505 OBERLIN RD STE 204 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276051345 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9198280035 | ||||||||
| FaxNumber: | 9198280355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C004242 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 133TF | 01 | NC | BCBS | OTHER | 8902730 | 05 | NC | MEDICAID |