Provider Demographics
NPI:1477141992
Name:JENKINS, EARNEST CALVIN BERNARD JR (MT013231)
Entity Type:Individual
Prefix:MR
First Name:EARNEST
Middle Name:CALVIN BERNARD
Last Name:JENKINS
Suffix:JR
Gender:M
Credentials:MT013231
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1335 ELDRICK LN
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-8335
Mailing Address - Country:US
Mailing Address - Phone:706-664-7882
Mailing Address - Fax:
Practice Address - Street 1:1335 ELDRICK LN
Practice Address - Street 2:
Practice Address - City:GROVETOWN
Practice Address - State:GA
Practice Address - Zip Code:30813-8335
Practice Address - Country:US
Practice Address - Phone:706-664-7882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-10
Last Update Date:2021-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT013231225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist