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General NPI Number Information
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NPI Number | 1710754643
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Entity Type | Individual
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Provider Name | TIFFANY KEISHA JENKINS PHD, NCSP
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Gender | Female
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Dates
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Enumeration Date | 12/11/2023
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Last Update Date | 12/11/2023
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Provider Practice Location Address
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Address Line | EVERGREEN COACHING AND COUNSELING 411 E PARK STREET, UNIT 106
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City | CHAMPAIGN
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State | IL
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Zip | 61820
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Country | US
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Telephone | 217-714-7042
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Fax |
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Provider Business Mailing Address
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Address Line | 203 W OREGON ST
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City | URBANA
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State | IL
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Zip | 61801-4123
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Country | US
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Telephone |
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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 | 103TS0200X
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Taxonomy Name | School Psychologist
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License Number |
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License Number State |
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