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General NPI Number Information
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NPI Number | 1558846196
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Entity Type | Individual
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Provider Name | LARRY JENKINS CACII, NCACII, B.S.
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Gender | Male
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Dates
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Enumeration Date | 09/29/2018
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Last Update Date | 03/14/2022
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Provider Practice Location Address
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Address Line | 116 PEACHTREE CT STE A
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City | PEACHTREE CITY
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State | GA
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Zip | 30269-4800
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Country | US
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Telephone | 770-719-1746
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Fax | 770-716-2368
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Provider Business Mailing Address
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Address Line | 41 FARMER ST STE 101
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City | NEWNAN
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State | GA
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Zip | 30263-8672
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Country | US
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Telephone | 770-683-3150
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Fax | 770-683-3151
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 1684CACII
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License Number State | GA
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