Provider Demographics
NPI:1356219828
Name:JENKINS, CRYSTAL JEWELL
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:JEWELL
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 1:910 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61104-2162
Mailing Address - Country:US
Mailing Address - Phone:844-473-6378
Mailing Address - Fax:270-246-9950
Practice Address - Street 1:910 2ND AVE
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2162
Practice Address - Country:US
Practice Address - Phone:844-473-6378
Practice Address - Fax:270-246-9950
Is Sole Proprietor?:No
Enumeration Date:2025-10-27
Last Update Date:2025-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1093307266106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician