Provider Demographics
NPI:1841684347
Name:JENKINS, LATRELL (CNA)
Entity type:Individual
Prefix:
First Name:LATRELL
Middle Name:
Last Name:JENKINS
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 1:208 CURTIS ST
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:GA
Mailing Address - Zip Code:30467-2432
Mailing Address - Country:US
Mailing Address - Phone:912-978-8282
Mailing Address - Fax:
Practice Address - Street 1:208 CURTIS ST
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:GA
Practice Address - Zip Code:30467-2432
Practice Address - Country:US
Practice Address - Phone:912-978-8282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-23
Last Update Date:2015-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA47-2636910374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA47-263-6910Medicaid