Provider Demographics
NPI:1912535790
Name:JEAKINS, CHELSIE JOLENE
Entity Type:Individual
Prefix:
First Name:CHELSIE
Middle Name:JOLENE
Last Name:JEAKINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 S KANSAS AVE
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88203-3730
Mailing Address - Country:US
Mailing Address - Phone:775-399-4817
Mailing Address - Fax:
Practice Address - Street 1:1510 S KANSAS AVE
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88203-3730
Practice Address - Country:US
Practice Address - Phone:775-399-4817
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-29
Last Update Date:2020-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA3204638658Medicaid