Basic Information
| Provider Information | |||||||||
| NPI: | 1356877716 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JENKINS | ||||||||
| FirstName: | DAMIAN | ||||||||
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| Credential: | CSFA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3480 CYPRESS ST | ||||||||
| Address2: | |||||||||
| City: | KINGMAN | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 864013830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7028598011 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1200 S MOHAVE AVE | ||||||||
| Address2: | |||||||||
| City: | PARKER | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85344 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9286699201 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2017 | ||||||||
| LastUpdateDate: | 05/04/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZC0007X | 172782 | CO | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant |
No ID Information.