Provider Demographics
NPI:1851893374
Name:JENKINS, DWAYNE ELVON
Entity Type:Individual
Prefix:MR
First Name:DWAYNE
Middle Name:ELVON
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 1:2015 MARTINS GRANT CT
Mailing Address - Street 2:
Mailing Address - City:CROWNSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21032-1932
Mailing Address - Country:US
Mailing Address - Phone:410-721-6353
Mailing Address - Fax:410-721-2071
Practice Address - Street 1:2015 MARTINS GRANT CT
Practice Address - Street 2:
Practice Address - City:CROWNSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21032-1932
Practice Address - Country:US
Practice Address - Phone:410-721-6353
Practice Address - Fax:410-721-2071
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-28
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDSC0671101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)