Healthcare Provider Details

I. General information

NPI: 1316420441
Provider Name (Legal Business Name): TONY L JENKINS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2018
Last Update Date: 10/10/2022
Certification Date: 10/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1291 STANLEY RD NW
KENNESAW GA
30152-4359
US

IV. Provider business mailing address

1291 STANLEY RD NW
KENNESAW GA
30152-4359
US

V. Phone/Fax

Practice location:
  • Phone: 770-427-0147
  • Fax:
Mailing address:
  • Phone: 770-427-0147
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC009950
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: