Provider Demographics
NPI:1063697019
Name:JENKINS, DETRIA S
Entity type:Individual
Prefix:MRS
First Name:DETRIA
Middle Name:S
Last Name:JENKINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1222
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71294-1222
Mailing Address - Country:US
Mailing Address - Phone:318-387-3545
Mailing Address - Fax:318-387-3541
Practice Address - Street 1:130 DESIARD ST
Practice Address - Street 2:SUITE 412
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-7319
Practice Address - Country:US
Practice Address - Phone:318-387-3545
Practice Address - Fax:318-387-3541
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-08
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 101Y00000X
LAPCA 140713747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant