Provider Demographics
NPI:1811409899
Name:JENKINS, LYDIA R (CDCA)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:R
Last Name:JENKINS
Suffix:
Gender:F
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3509 STATE ROUTE 522
Mailing Address - Street 2:
Mailing Address - City:WHEELERSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45694-8542
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15221 ST. RT. 124
Practice Address - Street 2:
Practice Address - City:PIKETON
Practice Address - State:OH
Practice Address - Zip Code:45661
Practice Address - Country:US
Practice Address - Phone:740-961-1295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-30
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHQMHS101YM0800X
OHCMS171M00000X
OHCDCA.167760101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator