Basic Information
| Provider Information | |||||||||
| NPI: | 1356845119 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JENKINS | ||||||||
| FirstName: | TAWNIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 964 N MARKET ST | ||||||||
| Address2: | |||||||||
| City: | LISBON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444329363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304241468 | ||||||||
| FaxNumber: | 3304249844 | ||||||||
| Practice Location | |||||||||
| Address1: | 964 N MARKET ST | ||||||||
| Address2: | |||||||||
| City: | LISBON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 444329363 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3304241468 | ||||||||
| FaxNumber: | 3304249844 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2018 | ||||||||
| LastUpdateDate: | 03/19/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | LCDCIII.161536 | OH | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | LCDCIII.161536 | 01 | OH | OHIO CHEMICAL DEPENDENCY PROFESSIONALS BOARD | OTHER |