Provider Demographics
NPI:1073192522
Name:JENKINS, SAMANTHA TAYLOR
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:TAYLOR
Last Name:JENKINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 E MAIN ST APT 202
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23219-3332
Mailing Address - Country:US
Mailing Address - Phone:757-504-8877
Mailing Address - Fax:
Practice Address - Street 1:9351 W BROAD ST
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23294-5437
Practice Address - Country:US
Practice Address - Phone:844-244-1818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-02
Last Update Date:2022-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician