Provider Demographics
NPI:1780216101
Name:JENKINS, ROSS
Entity Type:Individual
Prefix:
First Name:ROSS
Middle Name:
Last Name:JENKINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:902 STATE ROAD 570
Mailing Address - Street 2:
Mailing Address - City:RANCHOS DE TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87557-7916
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:579 WHITE SWAN ROAD
Practice Address - Street 2:
Practice Address - City:OHKAY OWINGEH
Practice Address - State:NM
Practice Address - Zip Code:87566
Practice Address - Country:US
Practice Address - Phone:505-852-2788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)