Healthcare Provider Details

I. General information

NPI: 1417530429
Provider Name (Legal Business Name): MRS. CEAN MARIE MAY JENKINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2021
Last Update Date: 04/29/2021
Certification Date: 04/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9007 N INDIAN TRAIL RD
SPOKANE WA
99208-9116
US

IV. Provider business mailing address

4712 N NELSON ST
SPOKANE WA
99217-5033
US

V. Phone/Fax

Practice location:
  • Phone: 509-464-2791
  • Fax:
Mailing address:
  • Phone: 509-723-9480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License NumberVA60168854
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: