Provider Demographics
NPI:1790374502
Name:JENKINS, FREDERICK MAUGER
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:MAUGER
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 1:337 BLACKLATCH LN
Mailing Address - Street 2:
Mailing Address - City:CAMP HILL
Mailing Address - State:PA
Mailing Address - Zip Code:17011-8413
Mailing Address - Country:US
Mailing Address - Phone:717-620-1291
Mailing Address - Fax:
Practice Address - Street 1:337 BLACKLATCH LN
Practice Address - Street 2:
Practice Address - City:CAMP HILL
Practice Address - State:PA
Practice Address - Zip Code:17011-8413
Practice Address - Country:US
Practice Address - Phone:717-620-1291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-15
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC000070101YM0800X
PS007922103TB0200X
PS007922L103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral