Provider Demographics
NPI:1730936642
Name:JENIKOVSKY, BROCK DEVERE CARTER (CADC-II, ICADC)
Entity type:Individual
Prefix:MR
First Name:BROCK
Middle Name:DEVERE CARTER
Last Name:JENIKOVSKY
Suffix:
Gender:M
Credentials:CADC-II, ICADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51165 EISENHOWER DR APT B
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-3084
Mailing Address - Country:US
Mailing Address - Phone:760-883-7441
Mailing Address - Fax:
Practice Address - Street 1:44359 PALM ST
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-3116
Practice Address - Country:US
Practice Address - Phone:760-342-6616
Practice Address - Fax:760-347-8276
Is Sole Proprietor?:No
Enumeration Date:2024-04-30
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA051980920101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)