Provider Demographics
NPI:1437683455
Name:JENKINS, KYLLIE (CAC, CCGC)
Entity Type:Individual
Prefix:
First Name:KYLLIE
Middle Name:
Last Name:JENKINS
Suffix:
Gender:F
Credentials:CAC, CCGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5925 GREENWELL SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-1620
Mailing Address - Country:US
Mailing Address - Phone:225-926-7911
Mailing Address - Fax:
Practice Address - Street 1:5925 GREENWELL SPRINGS RD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-1620
Practice Address - Country:US
Practice Address - Phone:225-926-7911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1389101YA0400X
LA1080101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)