MEDICARE: DEWAYNE G JENKINS

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	251E00000X	Home Health Agency		CA

General Provider Information

NPI Number	:	1396395323
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEWAYNE G JENKINS

Provider Business Mailing Address
First Line	:	10866 WILSHIRE BLVD STE 400
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90024-4338
Country	:	US
Telephone Number	:	877-553-1195
Fax Number	:

Provider Business Practice Location Address
First Line	:	2322 VINEYARD AVE APT 7
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90016-1641
Country	:	US
Telephone Number	:	310-774-6049
Fax Number	:

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

Provider Enumeration Date	:	09/11/2019
Last Update Date	:	09/11/2019

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