Provider Demographics
NPI:1154501013
Name:JENKINS, JUSTIN CHARLES
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:CHARLES
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 1:2914 S 14TH ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-2407
Mailing Address - Country:US
Mailing Address - Phone:253-227-6428
Mailing Address - Fax:253-565-7110
Practice Address - Street 1:6615 6TH AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-2027
Practice Address - Country:US
Practice Address - Phone:253-565-7110
Practice Address - Fax:253-565-7110
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMAOOO16111174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist