MEDICARE: MRS. JALETHA JENKINS LBSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	335E00000X	Prosthetic/Orthotic Supplier
2	104100000X	Social Worker	33900285A	IN

General Provider Information

NPI Number	:	1114703303
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. JALETHA JENKINS LBSW

Provider Business Mailing Address
First Line	:	6101 N KEYSTONE AVE STE 100
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46220-2499
Country	:	US
Telephone Number	:	317-296-5382
Fax Number	:

Provider Business Practice Location Address
First Line	:	2004 FREMONT ST
Second Line	:
City	:	SOUTH BEND
State	:	IN
Zip	:	46628-3153
Country	:	US
Telephone Number	:	317-296-5382
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/05/2023
Last Update Date	:	09/05/2023

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