Provider Demographics
NPI:1023489275
Name:JENKINS, MODENA (LSCSW)
Entity type:Individual
Prefix:
First Name:MODENA
Middle Name:
Last Name:JENKINS
Suffix:
Gender:F
Credentials:LSCSW
Other - Prefix:
Other - First Name:DENA
Other - Middle Name:
Other - Last Name:JENKINS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:434 N OHIO AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67214-3938
Mailing Address - Country:US
Mailing Address - Phone:316-409-6626
Mailing Address - Fax:316-776-4479
Practice Address - Street 1:434 N OHIO AVE
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67214-3938
Practice Address - Country:US
Practice Address - Phone:316-409-6626
Practice Address - Fax:316-776-4479
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-14
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS9524104100000X
KS054011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS201121550BMedicaid