Healthcare Provider Details

I. General information

NPI: 1831121136
Provider Name (Legal Business Name): CHARLES JENKS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 HAMMOND RD
THIELLS NY
10984-1201
US

IV. Provider business mailing address

81 PINE DR
STONY POINT NY
10980-2515
US

V. Phone/Fax

Practice location:
  • Phone: 845-942-3522
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: