Healthcare Provider Details

I. General information

NPI: 1609793694
Provider Name (Legal Business Name): SIMONE JENKINS
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2026
Last Update Date: 07/01/2026
Certification Date: 07/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 AVENTURA CT
RANDALLSTOWN MD
21133-4330
US

IV. Provider business mailing address

14 AVENTURA CT
RANDALLSTOWN MD
21133-4330
US

V. Phone/Fax

Practice location:
  • Phone: 410-258-5664
  • Fax:
Mailing address:
  • Phone: 410-258-5664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number10274923201
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: