Healthcare Provider Details

I. General information

NPI: 1811668155
Provider Name (Legal Business Name): AUTUMN RAIN RUSSELL JENKINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2021
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 LOCKHEED ST
CHARLESTON SC
29407-2248
US

IV. Provider business mailing address

607 LOCKHEED ST
CHARLESTON SC
29407-2248
US

V. Phone/Fax

Practice location:
  • Phone: 386-479-6538
  • Fax:
Mailing address:
  • Phone: 386-479-6538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-26-2849413
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: