Provider Demographics
NPI:1083163232
Name:JENKINS, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
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 1:136 ROSA LANE
Mailing Address - Street 2:
Mailing Address - City:QUITMAN
Mailing Address - State:GA
Mailing Address - Zip Code:31643
Mailing Address - Country:US
Mailing Address - Phone:229-561-2099
Mailing Address - Fax:
Practice Address - Street 1:136 ROSA LN
Practice Address - Street 2:
Practice Address - City:QUITMAN
Practice Address - State:GA
Practice Address - Zip Code:31643-3680
Practice Address - Country:US
Practice Address - Phone:229-561-2099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-29
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA586171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor