Provider Demographics
NPI:1386730927
Name:JENKINS, DAVID ETIENNE
Entity type:Individual
Prefix:MR
First Name:DAVID
Middle Name:ETIENNE
Last Name:JENKINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3525 PRESLEY AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-4453
Mailing Address - Country:US
Mailing Address - Phone:951-264-5699
Mailing Address - Fax:
Practice Address - Street 1:3525 PRESLEY AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-4453
Practice Address - Country:US
Practice Address - Phone:951-265-5699
Practice Address - Fax:951-686-1029
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
CARI-J1303210934101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health