=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104246719
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENYATTA AMEER JENKINS ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/22/2014
-----------------------------------------------------
Last Update Date | 04/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 808 S ELDORADO RD STE 2W
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61704-6034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-661-0232
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 59 FEDOR CIR
-----------------------------------------------------
City | BLOOMINGTON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61705-5108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-287-1459
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | 096003570
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------