Provider Demographics
NPI:1174009575
Name:JENKINS, KISHA (PHD)
Entity Type:Individual
Prefix:
First Name:KISHA
Middle Name:
Last Name:JENKINS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12530 S LAFLIN ST
Mailing Address - Street 2:
Mailing Address - City:CALUMET PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60827-6004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7801 YORK RD
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-7446
Practice Address - Country:US
Practice Address - Phone:410-847-7171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-18
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD06630103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist