Provider Demographics
NPI:1619752375
Name:JENKINS, EMILIA GLORIA
Entity Type:Individual
Prefix:
First Name:EMILIA
Middle Name:GLORIA
Last Name:JENKINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 W ALLEGAN ST
Mailing Address - Street 2:
Mailing Address - City:OTSEGO
Mailing Address - State:MI
Mailing Address - Zip Code:49078-1115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 WEST ALLEGAN STREET OTSEGO, MICHIGAN 49078
Practice Address - Street 2:
Practice Address - City:OTSEGO
Practice Address - State:MI
Practice Address - Zip Code:49078
Practice Address - Country:US
Practice Address - Phone:231-668-4909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician