Provider Demographics
NPI:1235840042
Name:JENKINS, MCKENZIE GRACE
Entity Type:Individual
Prefix:
First Name:MCKENZIE
Middle Name:GRACE
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 1:319 N 12TH ST UNIT 1
Mailing Address - Street 2:
Mailing Address - City:CORSICANA
Mailing Address - State:TX
Mailing Address - Zip Code:75110-4604
Mailing Address - Country:US
Mailing Address - Phone:903-641-8409
Mailing Address - Fax:
Practice Address - Street 1:319 N 12TH ST UNIT 1
Practice Address - Street 2:
Practice Address - City:CORSICANA
Practice Address - State:TX
Practice Address - Zip Code:75110-4604
Practice Address - Country:US
Practice Address - Phone:903-641-8409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-13
Last Update Date:2022-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty