=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073664967
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GERALD P. JENKINS DMIN
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/16/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 634 PEACHTREE PKWY SUITE 210
-----------------------------------------------------
City | CUMMING
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30041-9782
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 678-513-7676
-----------------------------------------------------
Fax | 770-844-0561
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2536 BALLANTRAE CIR
-----------------------------------------------------
City | CUMMING
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30041-6393
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-844-0794
-----------------------------------------------------
Fax | 770-844-0561
-----------------------------------------------------
=====================================================
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 | MFT000318
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------