Provider Demographics
NPI:1083261432
Name:JENKINS, DEXTER L SR (CDCA)
Entity Type:Individual
Prefix:MR
First Name:DEXTER
Middle Name:L
Last Name:JENKINS
Suffix:SR
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 W MONUMENT AVE FL 7
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45402-1274
Mailing Address - Country:US
Mailing Address - Phone:937-461-4300
Mailing Address - Fax:
Practice Address - Street 1:7301 POE AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-2559
Practice Address - Country:US
Practice Address - Phone:937-280-4631
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-21
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
OH178181101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1326012360OtherAGENCY NPI