MEDICARE: MRS. WANDA B. JENKINS LCSW, CCM

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	1041C0700X	Clinical Social Worker	27926	TX

General Provider Information

NPI Number	:	1851680474
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. WANDA B. JENKINS LCSW, CCM

Provider Business Mailing Address
First Line	:	8617 CHARLESTON AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-1715
Country	:	US
Telephone Number	:	817-559-3786
Fax Number	:

Provider Business Practice Location Address
First Line	:	8617 CHARLESTON AVE
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-1715
Country	:	US
Telephone Number	:	817-559-3786
Fax Number	:

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

Provider Enumeration Date	:	04/05/2011
Last Update Date	:	04/05/2011

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