Healthcare Provider Details

I. General information

NPI: 1154401552
Provider Name (Legal Business Name): LOUIS JENKINS PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11130 ANDERSON ST STE 117
LOMA LINDA CA
92354-2802
US

IV. Provider business mailing address

54701 FILE NUMBER
LOS ANGELES CA
90074-4701
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-8752
  • Fax:
Mailing address:
  • Phone: 909-558-3111
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY6079
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: