Basic Information
| Provider Information | |||||||||
| NPI: | 1457721391 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENKINS | ||||||||
| FirstName: | LATRICIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
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| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 103 4TH ST | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712513346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182591500 | ||||||||
| FaxNumber: | 3182591580 | ||||||||
| Practice Location | |||||||||
| Address1: | 103 4TH ST | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | LA | ||||||||
| PostalCode: | 712513346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182591500 | ||||||||
| FaxNumber: | 3182591580 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2015 | ||||||||
| LastUpdateDate: | 10/19/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
ID Information
| ID | Type | State | Issuer | Description | 1457721391 | 05 | LA | MEDICAID | 1457721391 | 01 | LA | CASE MANAGER | OTHER |