Provider Demographics
NPI:1679830616
Name:JENKINS, LYDIA
Entity Type:Individual
Prefix:MISS
First Name:LYDIA
Middle Name:
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 1:4345 CARTER CREEK DR.
Mailing Address - Street 2:9
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3975 STATE HIGHWAY 6 S
Practice Address - Street 2:SUITE 700
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845
Practice Address - Country:US
Practice Address - Phone:979-696-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-16
Last Update Date:2012-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT114234225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist