Healthcare Provider Details

I. General information

NPI: 1437683455
Provider Name (Legal Business Name): KYLLIE JENKINS CAC, CCGC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2017
Last Update Date: 04/06/2026
Certification Date: 04/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2751 WOODDALE BLVD STE A
BATON ROUGE LA
70805-7567
US

IV. Provider business mailing address

PO BOX 66558
BATON ROUGE LA
70896-6558
US

V. Phone/Fax

Practice location:
  • Phone: 225-362-5360
  • Fax: 855-473-0115
Mailing address:
  • Phone: 225-362-5360
  • Fax: 855-473-0115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number10600
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1080
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number1389
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: