Provider Demographics
NPI:1720672645
Name:JOHN MARSHALL JENKINS PHD LLC
Entity Type:Organization
Organization Name:JOHN MARSHALL JENKINS PHD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED PSYCHOLOGIST
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MARSHALL
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:706-766-1937
Mailing Address - Street 1:PO BOX 441
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30162-0441
Mailing Address - Country:US
Mailing Address - Phone:706-766-1937
Mailing Address - Fax:706-355-6061
Practice Address - Street 1:504 RIVERSIDE PKWY NE STE 110
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-2981
Practice Address - Country:US
Practice Address - Phone:706-766-1937
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-22
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
1861443921OtherNPPES INDIVIDUAL NPI
GAPSY001194OtherGEORGIA PSYCHOLOGIST LICENSE