Provider Demographics
NPI:1013528207
Name:JENKINS, STEPHEN SEAN (PHD, ABPP)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:SEAN
Last Name:JENKINS
Suffix:
Gender:M
Credentials:PHD, ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1411 W SAINT GERMAIN ST STE 105
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-4180
Mailing Address - Country:US
Mailing Address - Phone:320-253-3715
Mailing Address - Fax:320-252-2567
Practice Address - Street 1:1400 W SAINT GERMAIN ST STE 105
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-4101
Practice Address - Country:US
Practice Address - Phone:320-253-3715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-12
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4757103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical