Healthcare Provider Details

I. General information

NPI: 1275265761
Provider Name (Legal Business Name): KRIS JEAKINS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/24/2022
Last Update Date: 06/24/2022
Certification Date: 06/24/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3618 CANYON LAKE DR STE 107
RAPID CITY SD
57702-3129
US

IV. Provider business mailing address

109 SPRINGER DR
BOX ELDER SD
57719-9620
US

V. Phone/Fax

Practice location:
  • Phone: 605-430-4214
  • Fax:
Mailing address:
  • Phone: 605-430-4214
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: KRIS JEAKINS
Title or Position: OWNER
Credential: LPC
Phone: 605-430-4214