Provider Demographics
NPI:1316552912
Name:JENKINS, ANGELA (N/A)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:JENKINS
Suffix:
Gender:F
Credentials:N/A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 VIRGINIA ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01108-2623
Mailing Address - Country:US
Mailing Address - Phone:470-209-5678
Mailing Address - Fax:
Practice Address - Street 1:58 VIRGINIA ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01108-2623
Practice Address - Country:US
Practice Address - Phone:470-209-5678
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-10
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver