Provider Demographics
NPI:1124426275
Name:JENKINS, REBECCA SUE (CNA)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:SUE
Last Name:JENKINS
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:S
Other - Last Name:STAYTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3523 WHIPPOORWILL RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40213
Mailing Address - Country:US
Mailing Address - Phone:502-938-3683
Mailing Address - Fax:
Practice Address - Street 1:3523 WHIPPOORWILL RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40213
Practice Address - Country:US
Practice Address - Phone:502-938-3683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-05
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY50085884374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50085884OtherCNA CERTIFICATION NUMBER