Provider Demographics
NPI:1306384110
Name:JENKINS, KEVIN N (M ED)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:N
Last Name:JENKINS
Suffix:
Gender:M
Credentials:M ED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2065 TACKETTS VILLAGE SQ
Mailing Address - Street 2:APT. 301
Mailing Address - City:WOODBRIDGE
Mailing Address - State:VA
Mailing Address - Zip Code:22192-3425
Mailing Address - Country:US
Mailing Address - Phone:215-360-7981
Mailing Address - Fax:
Practice Address - Street 1:2065 TACKETTS VILLAGE SQ
Practice Address - Street 2:APT. 301
Practice Address - City:WOODBRIDGE
Practice Address - State:VA
Practice Address - Zip Code:22192-3425
Practice Address - Country:US
Practice Address - Phone:215-360-7981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-01
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC7667101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health