Healthcare Provider Details

I. General information

NPI: 1346989993
Provider Name (Legal Business Name): JENKINSON CO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2022
Last Update Date: 06/01/2022
Certification Date: 06/01/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 S WINMERE AVE
SELMA IN
47383-9427
US

IV. Provider business mailing address

500 S WINMERE AVE
SELMA IN
47383-9427
US

V. Phone/Fax

Practice location:
  • Phone: 765-748-8328
  • Fax:
Mailing address:
  • Phone: 765-748-8328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MAKAYLA BLACKMER
Title or Position: OWNER
Credential:
Phone: 765-748-8328