=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003407727
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EUNICE L JENKINS PHD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2021
-----------------------------------------------------
Last Update Date | 07/27/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4500 MERCANTILE PLAZA DR STE 300
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76137-4206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-273-4024
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 55038
-----------------------------------------------------
City | HURST
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76054-5038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-273-4024
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 203921
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------