Provider Demographics
NPI:1336888072
Name:JENKINS, ELLEN JESTER
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:JESTER
Last Name:JENKINS
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 1:3633 WHEELER RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-6549
Mailing Address - Country:US
Mailing Address - Phone:706-432-6866
Mailing Address - Fax:706-432-8775
Practice Address - Street 1:3506 PROFESSIONAL CIR STE B
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30907-8234
Practice Address - Country:US
Practice Address - Phone:706-210-8855
Practice Address - Fax:706-432-6866
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-01
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X
GAAPC008917101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional