Healthcare Provider Details

I. General information

NPI: 1477513182
Provider Name (Legal Business Name): GREG W. JENKINS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2006
Last Update Date: 07/13/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6010 W AMARILLO BLVD
AMARILLO TX
79106-1990
US

IV. Provider business mailing address

6010 W AMARILLO BLVD
AMARILLO TX
79106-1990
US

V. Phone/Fax

Practice location:
  • Phone: 806-355-9703
  • Fax: 806-468-1523
Mailing address:
  • Phone: 806-355-9703
  • Fax: 806-468-1523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number23079
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code103TA0400X
TaxonomyAddiction (Substance Use Disorder) Psychologist
License Number23079
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number23079
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number23079
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: