Provider Demographics
NPI:1558846196
Name:JENKINS, LARRY (CACII, NCACII, BS)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:
Last Name:JENKINS
Suffix:
Gender:M
Credentials:CACII, NCACII, BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:41 FARMER ST STE 101
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-8672
Mailing Address - Country:US
Mailing Address - Phone:770-683-3150
Mailing Address - Fax:770-683-3151
Practice Address - Street 1:116 PEACHTREE CT STE A
Practice Address - Street 2:
Practice Address - City:PEACHTREE CITY
Practice Address - State:GA
Practice Address - Zip Code:30269-4800
Practice Address - Country:US
Practice Address - Phone:770-719-1746
Practice Address - Fax:770-716-2368
Is Sole Proprietor?:No
Enumeration Date:2018-09-29
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1684CACII101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)