Provider Demographics
NPI:1215409750
Name:JENKINS, LAURA REGINA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:REGINA
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 1:4340 DECATUR DR APT 5305
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-9723
Mailing Address - Country:US
Mailing Address - Phone:706-414-6709
Mailing Address - Fax:
Practice Address - Street 1:4340 DECATUR DR APT 5305
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-9723
Practice Address - Country:US
Practice Address - Phone:706-414-6709
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-21
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME67592163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse