Basic Information
| Provider Information | |||||||||
| NPI: | 1750775524 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JENKINS | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PT, MSOTR | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 40 | ||||||||
| Address2: | |||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317760040 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 3131 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317686925 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2299853420 | ||||||||
| FaxNumber: | 2298919079 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2015 | ||||||||
| LastUpdateDate: | 03/19/2015 | ||||||||
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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 | 225100000X | PT001639 | GA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225X00000X | OT004065 | GA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist |
No ID Information.