Healthcare Provider Details

I. General information

NPI: 1669088415
Provider Name (Legal Business Name): EBONY M JENKINS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2020
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15637 INCA WAY
VICTORVILLE CA
92395-5515
US

IV. Provider business mailing address

15637 INCA WAY
VICTORVILLE CA
92395-5515
US

V. Phone/Fax

Practice location:
  • Phone: 760-792-8406
  • Fax:
Mailing address:
  • Phone: 760-792-8406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number137374
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: