Provider Demographics
NPI:1245788660
Name:JENKS, SUSAN (COTA)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:JENKS
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28628 SE 226TH STREET
Mailing Address - Street 2:
Mailing Address - City:MAPLE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98038-6900
Mailing Address - Country:US
Mailing Address - Phone:206-303-7034
Mailing Address - Fax:
Practice Address - Street 1:28628 SE 226TH ST
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038-6900
Practice Address - Country:US
Practice Address - Phone:206-303-7034
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-14
Last Update Date:2016-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOC60405133314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility