Provider Demographics
NPI:1407413685
Name:JENKINS, PRISCILLA KERUBO
Entity Type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:KERUBO
Last Name:JENKINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:341 TIOGA DR
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76002-4416
Mailing Address - Country:US
Mailing Address - Phone:817-696-1384
Mailing Address - Fax:
Practice Address - Street 1:341 TIOGA DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76002-4416
Practice Address - Country:US
Practice Address - Phone:817-696-1384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-23
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX306346164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse