Healthcare Provider Details

I. General information

NPI: 1922673540
Provider Name (Legal Business Name): MELINDA ROSE JENKINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2021
Last Update Date: 05/25/2021
Certification Date: 05/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 PENINSULA AVE
SAN MATEO CA
94401-1653
US

IV. Provider business mailing address

220 6TH ST
ROSEVILLE CA
95678-3912
US

V. Phone/Fax

Practice location:
  • Phone: 650-286-4396
  • Fax:
Mailing address:
  • Phone: 916-289-0151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: