Provider Demographics
NPI:1376922153
Name:JENKINS, CONNIE (LISW)
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:
Last Name:JENKINS
Suffix:
Gender:F
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3791 STATE ROUTE 63
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:OH
Mailing Address - Zip Code:45036-9371
Mailing Address - Country:US
Mailing Address - Phone:513-932-1211
Mailing Address - Fax:513-932-1320
Practice Address - Street 1:3791 STATE ROUTE 63
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:OH
Practice Address - Zip Code:45036-9371
Practice Address - Country:US
Practice Address - Phone:513-932-1211
Practice Address - Fax:513-932-1320
Is Sole Proprietor?:No
Enumeration Date:2015-05-26
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI 15003911041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical