Provider Demographics
NPI:1194801415
Name:JENKS, PAMELA JEAN (CADCIII)
Entity type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:JEAN
Last Name:JENKS
Suffix:
Gender:F
Credentials:CADCIII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 E EVANDALE DR
Mailing Address - Street 2:
Mailing Address - City:OAK CREEK
Mailing Address - State:WI
Mailing Address - Zip Code:53154-3015
Mailing Address - Country:US
Mailing Address - Phone:141-476-8031
Mailing Address - Fax:
Practice Address - Street 1:4811 S 76TH ST
Practice Address - Street 2:SUITE208
Practice Address - City:GREENFIELD
Practice Address - State:WI
Practice Address - Zip Code:53220-4364
Practice Address - Country:US
Practice Address - Phone:141-481-7044
Practice Address - Fax:141-481-7044
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI684101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39356400Medicaid