Provider Demographics
NPI:1265830632
Name:JENKINS, BEAU (ATC/LAT)
Entity Type:Individual
Prefix:
First Name:BEAU
Middle Name:
Last Name:JENKINS
Suffix:
Gender:M
Credentials:ATC/LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2714 W OXFORD LOOP
Mailing Address - Street 2:164
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5711
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 NORTHWEST PLZ
Practice Address - Street 2:164
Practice Address - City:SENATOBIA
Practice Address - State:MS
Practice Address - Zip Code:38668-1746
Practice Address - Country:US
Practice Address - Phone:662-812-1168
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-16
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSAT05352255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer