Provider Demographics
NPI:1518484849
Name:JENKINS, JASON TODD (MABC LPC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:TODD
Last Name:JENKINS
Suffix:
Gender:M
Credentials:MABC LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2811 ACADIA ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:TX
Mailing Address - Zip Code:75672-7507
Mailing Address - Country:US
Mailing Address - Phone:903-399-9208
Mailing Address - Fax:
Practice Address - Street 1:3800 PALUXY DR STE 240
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-1667
Practice Address - Country:US
Practice Address - Phone:903-283-8729
Practice Address - Fax:888-454-9083
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-28
Last Update Date:2017-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX73833101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty