Provider Demographics
NPI:1518247543
Name:JENKINS, JEFFREY KEITH I (LADC, LPC LMFT EMDR)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:KEITH
Last Name:JENKINS
Suffix:I
Gender:M
Credentials:LADC, LPC LMFT EMDR
Other - Prefix:MR
Other - First Name:JEFFREY
Other - Middle Name:KEITH
Other - Last Name:JENKINS
Other - Suffix:I
Other - Last Name Type:Professional Name
Other - Credentials:LADC, LPC LMFT EMDR
Mailing Address - Street 1:PO BOX 53
Mailing Address - Street 2:
Mailing Address - City:HENRYETTA
Mailing Address - State:OK
Mailing Address - Zip Code:74437-0053
Mailing Address - Country:US
Mailing Address - Phone:405-328-3620
Mailing Address - Fax:
Practice Address - Street 1:316 W MAIN ST
Practice Address - Street 2:
Practice Address - City:HENRYETTA
Practice Address - State:OK
Practice Address - Zip Code:74437-4240
Practice Address - Country:US
Practice Address - Phone:405-328-3620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-22
Last Update Date:2015-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPENDING101Y00000X, 101YM0800X, 106H00000X
OK101YA0400X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK45-2830942OtherEIN
OK73-1486908OtherEIN