Provider Demographics
NPI:1225398696
Name:JENKINS, MELISSA MCKEOWN (PHD)
Entity Type:Individual
Prefix:DR
First Name:MELISSA
Middle Name:MCKEOWN
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 1:1265 CARLSBAD VILLAGE DR STE 210C
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92008-1972
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1265 CARLSBAD VILLAGE DR STE 210C
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-1972
Practice Address - Country:US
Practice Address - Phone:858-354-4077
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-20
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA29819103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program