=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790411254
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARION LEARN JENKINS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/27/2022
-----------------------------------------------------
Last Update Date | 07/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 346 YORK AVE
-----------------------------------------------------
City | TOWANDA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18848-2021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-265-3996
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 212 HUFF HILL RD
-----------------------------------------------------
City | WYALUSING
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 18853-7894
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | DH003219L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------