Provider Demographics
NPI:1093425928
Name:JENKINS, CORNELIUS
Entity Type:Individual
Prefix:
First Name:CORNELIUS
Middle Name:
Last Name:JENKINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1224 SERENGETI WAY
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-2612
Mailing Address - Country:US
Mailing Address - Phone:321-614-5557
Mailing Address - Fax:407-960-3009
Practice Address - Street 1:1224 SERENGETI WAY
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-2612
Practice Address - Country:US
Practice Address - Phone:321-614-5557
Practice Address - Fax:407-960-3009
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-01
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician