1083162259 NPI number — GLYNDA LOUISE JENKINS LPC

Table of content: GLYNDA LOUISE JENKINS LPC (NPI 1083162259)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083162259 NPI number — GLYNDA LOUISE JENKINS LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JENKINS
Provider First Name:
GLYNDA
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083162259
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/16/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6810 CRUMPLER BLVD
Provider Second Line Business Mailing Address:
101
Provider Business Mailing Address City Name:
OLIVE BRANCH
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38654-1933
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-497-6827
Provider Business Mailing Address Fax Number:
662-890-0622

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6810 CRUMPLER BLVD
Provider Second Line Business Practice Location Address:
101
Provider Business Practice Location Address City Name:
OLIVE BRANCH
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38654-1933
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-497-6827
Provider Business Practice Location Address Fax Number:
662-890-0622
Provider Enumeration Date:
09/16/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  1810 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)