Basic Information
| Provider Information | |||||||||
| NPI: | 1346957537 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENKINS | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PEER SUPPORTER | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 425 MARION PIKE | ||||||||
| Address2: | |||||||||
| City: | COAL GROVE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456382960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406466640 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 425 MARION PIKE | ||||||||
| Address2: | |||||||||
| City: | COAL GROVE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 456382960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7406466640 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/28/2022 | ||||||||
| LastUpdateDate: | 10/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| NPICertificationDate: | 10/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | Y |
No ID Information.