Healthcare Provider Details

I. General information

NPI: 1588758056
Provider Name (Legal Business Name): DIANE A. JENKINS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 06/28/2021
Certification Date: 06/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4212 N. 16TH STREET
PHOENIX AZ
85016
US

IV. Provider business mailing address

PHOENIX INDIAN MEDICAL CENTER P O BOX 95460
CLEVELAND OH
44193
US

V. Phone/Fax

Practice location:
  • Phone: 602-263-1511
  • Fax: 602-263-1637
Mailing address:
  • Phone: 602-581-6088
  • Fax: 602-263-1619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW-11484
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: