Provider Demographics
NPI:1427893767
Name:JENKS, OLIVIA (LPE)
Entity type:Individual
Prefix:
First Name:OLIVIA
Middle Name:
Last Name:JENKS
Suffix:
Gender:F
Credentials:LPE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 INDIANA AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-4267
Mailing Address - Country:US
Mailing Address - Phone:909-717-6069
Mailing Address - Fax:
Practice Address - Street 1:6800 INDIANA AVE STE 205
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-4267
Practice Address - Country:US
Practice Address - Phone:909-717-6069
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-27
Last Update Date:2024-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
CAL9920207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No174400000XOther Service ProvidersSpecialist