Provider Demographics
NPI:1386081511
Name:JENKINS, SHANETIA (MS)
Entity type:Individual
Prefix:
First Name:SHANETIA
Middle Name:
Last Name:JENKINS
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 SW BOATSMAN AVE
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73505-9515
Mailing Address - Country:US
Mailing Address - Phone:580-536-4666
Mailing Address - Fax:
Practice Address - Street 1:602 SW A AVE
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73501-3930
Practice Address - Country:US
Practice Address - Phone:580-678-7452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-29
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171W00000XOther Service ProvidersContractor