Provider Demographics
NPI:1811535875
Name:JENKS, HEATHER M (CNA)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:M
Last Name:JENKS
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 MCINTYRE ST APT C2
Mailing Address - Street 2:
Mailing Address - City:FORT EDWARD
Mailing Address - State:NY
Mailing Address - Zip Code:12828-1644
Mailing Address - Country:US
Mailing Address - Phone:518-630-1298
Mailing Address - Fax:
Practice Address - Street 1:40 MCINTYRE ST APT C2
Practice Address - Street 2:
Practice Address - City:FORT EDWARD
Practice Address - State:NY
Practice Address - Zip Code:12828-1644
Practice Address - Country:US
Practice Address - Phone:518-630-1298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-20
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY343409570513E376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH41731474Medicaid