Healthcare Provider Details

I. General information

NPI: 1992187538
Provider Name (Legal Business Name): D'ETTA MARIA JENKINS DNP, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2015
Last Update Date: 06/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 BLARNEY CT
DUBLIN GA
31021-0793
US

IV. Provider business mailing address

805 BLARNEY CT
DUBLIN GA
31021-0793
US

V. Phone/Fax

Practice location:
  • Phone: 478-290-5757
  • Fax:
Mailing address:
  • Phone: 478-290-5757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF0615110
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN097928
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: