Healthcare Provider Details

I. General information

NPI: 1699685164
Provider Name (Legal Business Name): JUSTIN JENKINS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2026
Last Update Date: 09/08/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 MCNALLY ST
GOSHEN NY
10924-1103
US

IV. Provider business mailing address

4012 57TH TER
VERO BEACH FL
32966-1878
US

V. Phone/Fax

Practice location:
  • Phone: 908-514-1634
  • Fax:
Mailing address:
  • Phone: 908-514-1634
  • Fax: 845-477-1294

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-25-472432
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: