Provider Demographics
NPI:1396395323
Name:JENKINS, DEWAYNE G
Entity Type:Individual
Prefix:
First Name:DEWAYNE
Middle Name:G
Last Name:JENKINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10866 WILSHIRE BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90024-4338
Mailing Address - Country:US
Mailing Address - Phone:877-553-1195
Mailing Address - Fax:
Practice Address - Street 1:2322 VINEYARD AVE APT 7
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90016-1641
Practice Address - Country:US
Practice Address - Phone:310-774-6049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-11
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health