Healthcare Provider Details

I. General information

NPI: 1316552912
Provider Name (Legal Business Name): ANGELA JENKINS N/A
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2020
Last Update Date: 09/22/2020
Certification Date: 09/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 VIRGINIA ST
SPRINGFIELD MA
01108-2623
US

IV. Provider business mailing address

58 VIRGINIA ST
SPRINGFIELD MA
01108-2623
US

V. Phone/Fax

Practice location:
  • Phone: 470-209-5678
  • Fax:
Mailing address:
  • Phone: 470-209-5678
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: