Basic Information
| Provider Information | |||||||||
| NPI: | 1770823809 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENKINS | ||||||||
| FirstName: | PERRY | ||||||||
| MiddleName: | SAMUEL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PMHNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 204 KALI CT | ||||||||
| Address2: | |||||||||
| City: | RICHLANDS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285748425 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104676865 | ||||||||
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| Practice Location | |||||||||
| Address1: | 110 BRANCHWOOD DR STE B | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 285465900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9109389833 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2013 | ||||||||
| LastUpdateDate: | 12/17/2013 | ||||||||
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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 | 363LP0808X | 229335 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.