Provider Demographics
NPI:1194188409
Name:JENKINS, LATASHA (RN)
Entity Type:Individual
Prefix:
First Name:LATASHA
Middle Name:
Last Name:JENKINS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1589
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72018-1589
Mailing Address - Country:US
Mailing Address - Phone:501-315-3344
Mailing Address - Fax:
Practice Address - Street 1:1502 MARY KAY BLVD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-7201
Practice Address - Country:US
Practice Address - Phone:501-315-3344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-04
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR097931163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse