Healthcare Provider Details

I. General information

NPI: 1205119062
Provider Name (Legal Business Name): RUSSELL ALDEN JENKINS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2011
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5901 E 7TH ST # 116B
LONG BEACH CA
90822-5201
US

IV. Provider business mailing address

5901 E 7TH ST # 116B
LONG BEACH CA
90822-5201
US

V. Phone/Fax

Practice location:
  • Phone: 310-290-9728
  • Fax: 814-860-2110
Mailing address:
  • Phone: 310-290-9728
  • Fax: 814-860-2110

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY33064
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: