Healthcare Provider Details

I. General information

NPI: 1053950709
Provider Name (Legal Business Name): COLLEEN JENKINS MS, LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2019
Last Update Date: 12/29/2019
Certification Date: 12/29/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35 STANDLEY ST
BEVERLY MA
01915-2099
US

IV. Provider business mailing address

35 STANDLEY ST
BEVERLY MA
01915-2099
US

V. Phone/Fax

Practice location:
  • Phone: 978-927-8793
  • Fax:
Mailing address:
  • Phone: 978-927-8793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: