MEDICARE: MR. JERMAINE D 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	172A00000X	Driver

General Provider Information

NPI Number	:	1558097220
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JERMAINE D JENKINS

Provider Business Mailing Address
First Line	:	13846 BONNER BLUFF LN
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77047-3769
Country	:	US
Telephone Number	:	832-557-6464
Fax Number	:

Provider Business Practice Location Address
First Line	:	2901 WILCREST DR STE 400-22
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77042-3399
Country	:	US
Telephone Number	:	832-557-6464
Fax Number	:

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

Provider Enumeration Date	:	07/26/2022
Last Update Date	:	08/23/2022

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