Healthcare Provider Details

I. General information

NPI: 1396562807
Provider Name (Legal Business Name): DARRYL ANTHONY JENKINS JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2024
Last Update Date: 10/22/2024
Certification Date: 10/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1780 STEWART PL
MELBOURNE FL
32935-4304
US

IV. Provider business mailing address

478 N BABCOCK ST STE 115
MELBOURNE FL
32935-6923
US

V. Phone/Fax

Practice location:
  • Phone: 321-831-7834
  • Fax:
Mailing address:
  • Phone: 321-972-4265
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-24-386978
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: