Healthcare Provider Details

I. General information

NPI: 1588711154
Provider Name (Legal Business Name): TINA LINETTE JENKINS I
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 01/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 S CEDAR AVE
FRESNO CA
93702-2908
US

IV. Provider business mailing address

515 S CEDAR AVE
FRESNO CA
93702-2908
US

V. Phone/Fax

Practice location:
  • Phone: 559-600-6069
  • Fax: 559-600-6090
Mailing address:
  • Phone: 559-600-6069
  • Fax: 559-600-6090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number133577
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: