Provider Demographics
NPI:1104246719
Name:JENKINS, KENYATTA AMEER (ATC)
Entity type:Individual
Prefix:MR
First Name:KENYATTA
Middle Name:AMEER
Last Name:JENKINS
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 FEDOR CIR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61705-5108
Mailing Address - Country:US
Mailing Address - Phone:309-287-1459
Mailing Address - Fax:
Practice Address - Street 1:808 S ELDORADO RD STE 2W
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61704-6034
Practice Address - Country:US
Practice Address - Phone:309-661-0232
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-22
Last Update Date:2014-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960035702255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer