Healthcare Provider Details

I. General information

NPI: 1366121956
Provider Name (Legal Business Name): JEFFREY JENKS M.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2023
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 S CARMEL ST
CADILLAC MI
49601-2344
US

IV. Provider business mailing address

115 WHITE PINE VILLAGE DR
CADILLAC MI
49601-8004
US

V. Phone/Fax

Practice location:
  • Phone: 231-775-6517
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6352000576
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: