Provider Demographics
NPI:1861443921
Name:JENKINS, JOHN MARSHALL (PHD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MARSHALL
Last Name:JENKINS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 490246
Mailing Address - Street 2:
Mailing Address - City:MOUNT BERRY
Mailing Address - State:GA
Mailing Address - Zip Code:30149-0246
Mailing Address - Country:US
Mailing Address - Phone:706-766-1937
Mailing Address - Fax:706-238-7853
Practice Address - Street 1:712 W 2ND ST
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30161-2933
Practice Address - Country:US
Practice Address - Phone:706-766-1937
Practice Address - Fax:706-238-7853
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY001194103TC1900X
NC1399103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAR12582Medicare UPIN
GA68BBGRRMedicare ID - Type Unspecified