Provider Demographics
NPI:1386975241
Name:JENKINS, COURTNEY CARUTHA (MT)
Entity type:Individual
Prefix:
First Name:COURTNEY
Middle Name:CARUTHA
Last Name:JENKINS
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1761 HOTEL CIR S
Mailing Address - Street 2:108-109
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3318
Mailing Address - Country:US
Mailing Address - Phone:619-422-1544
Mailing Address - Fax:
Practice Address - Street 1:1761 HOTEL CIR S
Practice Address - Street 2:108-109
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3318
Practice Address - Country:US
Practice Address - Phone:619-422-1544
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-15
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2109174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist