Provider Demographics
NPI:1366104390
Name:JENKINS, MATTHEW (CDCA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:JENKINS
Suffix:
Gender:M
Credentials:CDCA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 WARD RD
Mailing Address - Street 2:
Mailing Address - City:BIDWELL
Mailing Address - State:OH
Mailing Address - Zip Code:45614-9342
Mailing Address - Country:US
Mailing Address - Phone:740-645-9382
Mailing Address - Fax:
Practice Address - Street 1:32 PORTSMOUTH ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:OH
Practice Address - Zip Code:45640-1622
Practice Address - Country:US
Practice Address - Phone:740-286-2918
Practice Address - Fax:740-286-1374
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-07
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCDCA.175539101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)