Provider Demographics
NPI:1538821285
Name:JENKINS, DEONDRAY D
Entity type:Individual
Prefix:
First Name:DEONDRAY
Middle Name:D
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 1:337 CAPITOL ST
Mailing Address - Street 2:
Mailing Address - City:NEW MADRID
Mailing Address - State:MO
Mailing Address - Zip Code:63869-1803
Mailing Address - Country:US
Mailing Address - Phone:573-521-9184
Mailing Address - Fax:
Practice Address - Street 1:337 CAPITOL ST
Practice Address - Street 2:
Practice Address - City:NEW MADRID
Practice Address - State:MO
Practice Address - Zip Code:63869-1803
Practice Address - Country:US
Practice Address - Phone:573-521-9184
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-11
Last Update Date:2021-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer