Basic Information
| Provider Information | |||||||||
| NPI: | 1871912873 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JENKINS | ||||||||
| FirstName: | EDDIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 OLIVE ST | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711042312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184297500 | ||||||||
| FaxNumber: | 3182276179 | ||||||||
| Practice Location | |||||||||
| Address1: | 856 TEXAS AVE | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711013400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3184268096 | ||||||||
| FaxNumber: | 3182276179 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2014 | ||||||||
| LastUpdateDate: | 09/25/2018 | ||||||||
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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 | 101YP2500X | 1594 | LA | N | Behavioral Health & Social Service Providers | Counselor | Professional | 1041C0700X | 1594 | LA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 1417252230 | 05 | LA | MEDICAID |