Provider Demographics
NPI:1104284900
Name:JENKINS, BRIDGET
Entity type:Individual
Prefix:
First Name:BRIDGET
Middle Name:
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 1:687 CHESHIRE AVE
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-5060
Mailing Address - Country:US
Mailing Address - Phone:541-684-4168
Mailing Address - Fax:541-684-4156
Practice Address - Street 1:1200 HILYARD ST STE 570
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-8168
Practice Address - Country:US
Practice Address - Phone:458-205-7070
Practice Address - Fax:458-205-7089
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-08
Last Update Date:2018-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16-05-21101YA0400X
101YM0800X
OR175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500719317Medicaid