Provider Demographics
NPI:1649938127
Name:JENKINS, MAYLA M (CPHT)
Entity type:Individual
Prefix:
First Name:MAYLA
Middle Name:M
Last Name:JENKINS
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 SAINT JAMES PL
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:IL
Mailing Address - Zip Code:61764-2126
Mailing Address - Country:US
Mailing Address - Phone:815-579-8077
Mailing Address - Fax:
Practice Address - Street 1:1305 N CAROLYN DR
Practice Address - Street 2:
Practice Address - City:MINONK
Practice Address - State:IL
Practice Address - Zip Code:61760-9326
Practice Address - Country:US
Practice Address - Phone:309-432-3451
Practice Address - Fax:309-432-3625
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-02
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL049191444183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician