Provider Demographics
NPI:1578591863
Name:JENKINS, PAMELA L (PHD)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:L
Last Name:JENKINS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5284 FLOYD RD SW
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126-6124
Mailing Address - Country:US
Mailing Address - Phone:404-590-8156
Mailing Address - Fax:206-350-3122
Practice Address - Street 1:1378 OAKDALE AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94124-2724
Practice Address - Country:US
Practice Address - Phone:415-637-0695
Practice Address - Fax:206-350-3122
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20240103TB0200X, 103TC2200X
GAPSY 003657103TC0700X, 103TC2200X, 103TB0200X
CAPSY 20240103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003134412CMedicaid
CA43274Medicaid