=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417392515
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEW BALANCE SERVICES,
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/02/2013
-----------------------------------------------------
Last Update Date | 05/02/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1625 CAMDEN WAY
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73013-2942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-328-3620
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1625 CAMDEN WAY
-----------------------------------------------------
City | EDMOND
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 73013-2942
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 405-328-3620
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | THERAPIST
-----------------------------------------------------
Name | MR. JEFFREY KEITH JENKINS I
-----------------------------------------------------
Credential | LPC, LMFT
-----------------------------------------------------
Telephone | 405-328-3620
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YA0400X
-----------------------------------------------------
Taxonomy Name | Addiction (Substance Use Disorder) Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 101YS0200X
-----------------------------------------------------
Taxonomy Name | School Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103TA0700X
-----------------------------------------------------
Taxonomy Name | Adult Development & Aging Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 103TB0200X
-----------------------------------------------------
Taxonomy Name | Cognitive & Behavioral Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 103TF0000X
-----------------------------------------------------
Taxonomy Name | Family Psychologist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OK
-----------------------------------------------------