Provider Demographics
NPI:1093012528
Name:JENKINS, KRISTEENA
Entity Type:Individual
Prefix:
First Name:KRISTEENA
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 1:10101 LINN STATION RD SUITE 600
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223
Mailing Address - Country:US
Mailing Address - Phone:502-589-8600
Mailing Address - Fax:
Practice Address - Street 1:300 FOXGLOVE DR
Practice Address - Street 2:
Practice Address - City:MT STERLING
Practice Address - State:KY
Practice Address - Zip Code:40353-9769
Practice Address - Country:US
Practice Address - Phone:859-498-2135
Practice Address - Fax:859-498-7957
Is Sole Proprietor?:No
Enumeration Date:2011-02-18
Last Update Date:2017-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
KY173587103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30610026Medicaid