Provider Demographics
NPI:1437524170
Name:TISHA R. JENKINS, LCSW P.A.
Entity Type:Organization
Organization Name:TISHA R. JENKINS, LCSW P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TISHA
Authorized Official - Middle Name:R
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:501-786-9308
Mailing Address - Street 1:302 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:AR
Mailing Address - Zip Code:72104-3737
Mailing Address - Country:US
Mailing Address - Phone:501-786-9308
Mailing Address - Fax:
Practice Address - Street 1:302 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MALVERN
Practice Address - State:AR
Practice Address - Zip Code:72104-3737
Practice Address - Country:US
Practice Address - Phone:501-786-9308
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-07
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR4482-C1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty