Provider Demographics
NPI:1114568847
Name:JENKINS, KATIE ALYSSA
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:ALYSSA
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 1:2704 N OAK ST BLDG A2
Mailing Address - Street 2:
Mailing Address - City:VALDOSTA
Mailing Address - State:GA
Mailing Address - Zip Code:31602-5900
Mailing Address - Country:US
Mailing Address - Phone:229-253-1009
Mailing Address - Fax:229-253-1039
Practice Address - Street 1:2704 N OAK ST BLDG A2
Practice Address - Street 2:
Practice Address - City:VALDOSTA
Practice Address - State:GA
Practice Address - Zip Code:31602-5900
Practice Address - Country:US
Practice Address - Phone:229-253-1009
Practice Address - Fax:229-253-1039
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPCET002847235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist