Provider Demographics
NPI:1366993123
Name:JENKINS, KYLE (MFTI)
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:JENKINS
Suffix:
Gender:M
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5362 LEMEE LN
Mailing Address - Street 2:P.O. BOX 99
Mailing Address - City:MARIPOSA
Mailing Address - State:CA
Mailing Address - Zip Code:95338-9556
Mailing Address - Country:US
Mailing Address - Phone:209-742-0810
Mailing Address - Fax:209-966-8251
Practice Address - Street 1:5362 LEMEE LN
Practice Address - Street 2:
Practice Address - City:MARIPOSA
Practice Address - State:CA
Practice Address - Zip Code:95338-9556
Practice Address - Country:US
Practice Address - Phone:209-742-0810
Practice Address - Fax:209-966-8251
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF94293106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist