Provider Demographics
NPI:1083742282
Name:JENKINS, TINA MARIE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:MARIE
Last Name:JENKINS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9881 BROKEN LAND PARKWAY
Mailing Address - Street 2:SUITE 105
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21046
Mailing Address - Country:US
Mailing Address - Phone:410-381-2874
Mailing Address - Fax:410-381-2875
Practice Address - Street 1:9881 BROKEN LAND PARKWAY
Practice Address - Street 2:SUITE 105
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21046
Practice Address - Country:US
Practice Address - Phone:410-381-2874
Practice Address - Fax:410-381-2875
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD04243103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD014158500Medicaid
MD20-8144144OtherTAX ID NUMBER
MD20-8144144OtherTAX ID NUMBER