Healthcare Provider Details

I. General information

NPI: 1902134943
Provider Name (Legal Business Name): JONATHAN JENKINS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2009
Last Update Date: 01/28/2023
Certification Date: 01/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

247 MCLAWS CIR
WILLIAMSBURG VA
23185-5660
US

IV. Provider business mailing address

1657 MERRIMAC TRL
WILLIAMSBURG VA
23185-5624
US

V. Phone/Fax

Practice location:
  • Phone: 757-253-0111
  • Fax:
Mailing address:
  • Phone: 757-220-3200
  • Fax: 757-253-4371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number0701004718
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: