Healthcare Provider Details

I. General information

NPI: 1447052824
Provider Name (Legal Business Name): NATHANIEL KEITH JENKINS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2025
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 MAGIC HOLLOW BLVD
VIRGINIA BEACH VA
23453-3010
US

IV. Provider business mailing address

3101 MAGIC HOLLOW BLVD
VIRGINIA BEACH VA
23453-3010
US

V. Phone/Fax

Practice location:
  • Phone: 757-639-2218
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: