Provider Demographics
NPI:1396562807
Name:JENKINS, DARRYL ANTHONY JR
Entity type:Individual
Prefix:
First Name:DARRYL
Middle Name:ANTHONY
Last Name:JENKINS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:478 N BABCOCK ST STE 115
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-6923
Mailing Address - Country:US
Mailing Address - Phone:321-972-4265
Mailing Address - Fax:
Practice Address - Street 1:1780 STEWART PL
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-4304
Practice Address - Country:US
Practice Address - Phone:321-831-7834
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-25
Last Update Date:2024-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRBT-24-386978106S00000X
106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician