Provider Demographics
NPI:1427759109
Name:JENKINS, SHANTAE (LPN)
Entity type:Individual
Prefix:MS
First Name:SHANTAE
Middle Name:
Last Name:JENKINS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:SHANTAE
Other - Middle Name:
Other - Last Name:JENKINS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:630 E CHELTEN AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19144-1205
Mailing Address - Country:US
Mailing Address - Phone:267-616-8664
Mailing Address - Fax:
Practice Address - Street 1:630 E CHELTEN AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19144-1205
Practice Address - Country:US
Practice Address - Phone:267-616-8664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-10
Last Update Date:2023-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN296983164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse