Provider Demographics
NPI:1205119062
Name:JENKINS, RUSSELL ALDEN (PHD)
Entity type:Individual
Prefix:DR
First Name:RUSSELL
Middle Name:ALDEN
Last Name:JENKINS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 E 38TH ST
Mailing Address - Street 2:BEHAVIORAL HEALTH CLINIC (BLDG 5)
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16504-1559
Mailing Address - Country:US
Mailing Address - Phone:814-860-2038
Mailing Address - Fax:814-860-2110
Practice Address - Street 1:135 E 38TH ST
Practice Address - Street 2:BEHAVIORAL HEALTH CLINIC (BLDG 5)
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16504-1559
Practice Address - Country:US
Practice Address - Phone:814-860-2038
Practice Address - Fax:814-860-2110
Is Sole Proprietor?:No
Enumeration Date:2011-09-27
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY 60178857103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical