Provider Demographics
NPI:1437546793
Name:JENKINS, BRUCE (LCSW)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:
Last Name:JENKINS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 440219
Mailing Address - Street 2:
Mailing Address - City:KOOSHAREM
Mailing Address - State:UT
Mailing Address - Zip Code:84744-0219
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:410 N 100 E
Practice Address - Street 2:
Practice Address - City:KOOSHAREM
Practice Address - State:UT
Practice Address - Zip Code:84744-7700
Practice Address - Country:US
Practice Address - Phone:435-638-7318
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-23
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT141354-35011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical