Healthcare Provider Details

I. General information

NPI: 1346871803
Provider Name (Legal Business Name): NASTASSJA JENKINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2020
Last Update Date: 02/03/2020
Certification Date: 02/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 HABITAT ST
AMERICUS GA
31709-3472
US

IV. Provider business mailing address

120 N DUDLEY ST
AMERICUS GA
31709-3410
US

V. Phone/Fax

Practice location:
  • Phone: 229-591-0465
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: