Provider Demographics
NPI:1285298463
Name:JENKINS, KIMBERLY L I
Entity type:Individual
Prefix:MISS
First Name:KIMBERLY
Middle Name:L
Last Name:JENKINS
Suffix:I
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 1:226 BEACH 98TH ST # 3
Mailing Address - Street 2:
Mailing Address - City:ROCKAWAY PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11694-2849
Mailing Address - Country:US
Mailing Address - Phone:718-569-0508
Mailing Address - Fax:833-318-2363
Practice Address - Street 1:226 BEACH 98TH ST # 3
Practice Address - Street 2:
Practice Address - City:ROCKAWAY PARK
Practice Address - State:NY
Practice Address - Zip Code:11694-2849
Practice Address - Country:US
Practice Address - Phone:718-569-0508
Practice Address - Fax:833-318-2363
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-24
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00483595251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00483595Medicaid