Provider Demographics
NPI:1184188799
Name:JENKINS, FUTURE LYNN RENEE
Entity Type:Individual
Prefix:
First Name:FUTURE
Middle Name:LYNN RENEE
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 1:3022 WINGATE DR SE APT 1B
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-2731
Mailing Address - Country:US
Mailing Address - Phone:616-589-1383
Mailing Address - Fax:
Practice Address - Street 1:2925 BRETON RD SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49512-1745
Practice Address - Country:US
Practice Address - Phone:616-243-4336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIJ525264564881Medicaid