Provider Demographics
NPI:1083162259
Name:JENKINS, GLYNDA LOUISE (LPC)
Entity type:Individual
Prefix:
First Name:GLYNDA
Middle Name:LOUISE
Last Name:JENKINS
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6810 CRUMPLER BLVD
Mailing Address - Street 2:101
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-1933
Mailing Address - Country:US
Mailing Address - Phone:901-497-6827
Mailing Address - Fax:662-890-0622
Practice Address - Street 1:6810 CRUMPLER BLVD
Practice Address - Street 2:101
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-1933
Practice Address - Country:US
Practice Address - Phone:901-497-6827
Practice Address - Fax:662-890-0622
Is Sole Proprietor?:No
Enumeration Date:2016-09-16
Last Update Date:2016-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1810101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS81-3815000OtherEIN