Healthcare Provider Details

I. General information

NPI: 1639752058
Provider Name (Legal Business Name): TONYA TOMIKA JENKINS CERTIFIED HAIR LOSS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2021
Last Update Date: 05/03/2021
Certification Date: 05/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 WYATT LN
SUMMERVILLE SC
29485-8769
US

IV. Provider business mailing address

106 WYATT LN
SUMMERVILLE SC
29485-8769
US

V. Phone/Fax

Practice location:
  • Phone: 843-330-9949
  • Fax:
Mailing address:
  • Phone: 843-330-9949
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1744P3200X
TaxonomyProsthetics Case Management
License Number91986
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: