Provider Demographics
NPI:1770501058
Name:JENKINS, HARRIET DIANE (LCSW)
Entity Type:Individual
Prefix:
First Name:HARRIET
Middle Name:DIANE
Last Name:JENKINS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:H.
Other - Middle Name:DIANE
Other - Last Name:JENKINS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:2820 NORTHBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6517
Mailing Address - Country:US
Mailing Address - Phone:336-768-8670
Mailing Address - Fax:
Practice Address - Street 1:110 WEST ELM STREET
Practice Address - Street 2:
Practice Address - City:YADKINVILLE
Practice Address - State:NC
Practice Address - Zip Code:27055-3313
Practice Address - Country:US
Practice Address - Phone:336-575-3747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2007-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0026451041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6003126Medicaid