Provider Demographics
NPI:1487414140
Name:JENKINS, CRYSTAL LYNN (MA)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:LYNN
Last Name:JENKINS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:CRYSTAL
Other - Middle Name:LYNN
Other - Last Name:HACKATHORNE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1331 SEMINOLE AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45506-3221
Mailing Address - Country:US
Mailing Address - Phone:326-209-2679
Mailing Address - Fax:
Practice Address - Street 1:1331 SEMINOLE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45506-3221
Practice Address - Country:US
Practice Address - Phone:326-209-2679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-20
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide