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General NPI Number Information
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NPI Number | 1558247486
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Entity Type | Individual
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Provider Name | RAQUEL JENKINS
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Gender | Female
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Dates
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Enumeration Date | 08/14/2025
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Last Update Date | 08/14/2025
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Provider Practice Location Address
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Address Line | 13755 OLD HALLS FERRY RD
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City | BLACK JACK
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State | MO
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Zip | 63033-4129
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Country | US
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Telephone | 314-915-3358
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Fax |
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Provider Business Mailing Address
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Address Line | 61 BROOKHILL CT
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City | COLLINSVILLE
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State | IL
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Zip | 62234-6044
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Country | US
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Telephone | 314-915-3358
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 405300000X
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Taxonomy Name | Prevention Professional
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License Number | 855544
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License Number State | MO
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