Provider Demographics
NPI:1295145985
Name:JENKS, CHARLES WILLIAM
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:WILLIAM
Last Name:JENKS
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 1:1246 YELLOWSTONE AVE STE C5
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4373
Mailing Address - Country:US
Mailing Address - Phone:208-233-0150
Mailing Address - Fax:208-233-0159
Practice Address - Street 1:1246 YELLOWSTONE AVE STE C5
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4373
Practice Address - Country:US
Practice Address - Phone:208-233-0150
Practice Address - Fax:208-233-0159
Is Sole Proprietor?:No
Enumeration Date:2014-05-02
Last Update Date:2014-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor