Healthcare Provider Details

I. General information

NPI: 1730936642
Provider Name (Legal Business Name): BROCK DEVERE CARTER JENIKOVSKY CADC III, ICADC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2024
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44359 PALM ST
INDIO CA
92201-3116
US

IV. Provider business mailing address

44359 PALM ST
INDIO CA
92201-3116
US

V. Phone/Fax

Practice location:
  • Phone: 760-342-6616
  • Fax: 760-347-8276
Mailing address:
  • Phone: 760-883-7441
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberA051980920
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: