Provider Demographics
NPI:1639708944
Name:JENKINS, MIA NOELLE (MS CF-SLP)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:NOELLE
Last Name:JENKINS
Suffix:
Gender:F
Credentials:MS CF-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 TANGERINE WAY
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33483-6119
Mailing Address - Country:US
Mailing Address - Phone:301-639-2334
Mailing Address - Fax:
Practice Address - Street 1:301 NORTHPOINT PKWY
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33407-7904
Practice Address - Country:US
Practice Address - Phone:561-712-1717
Practice Address - Fax:561-712-1118
Is Sole Proprietor?:No
Enumeration Date:2020-04-07
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSZ9547235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDJJQ810359158OtherCAREFIRST BLUECHOICE, INC.