=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336375245
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NELLIE LAVERN JENKINS-KENDRICK LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2009
-----------------------------------------------------
Last Update Date | 04/10/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16838 E 8 MILE RD
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48205-1519
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-245-0870
-----------------------------------------------------
Fax | 313-245-0575
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16844 PRINCETON ST
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48221-3157
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-397-3216
-----------------------------------------------------
Fax | 313-397-3216
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801079706
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------