Basic Information
Provider Information
NPI: 1003292046
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: JENKINS
FirstName: KIARA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1184 PEARL ST SW
Address2:  
City: WARREN
State: OH
PostalCode: 444853650
CountryCode: US
TelephoneNumber: 5672193045
FaxNumber:  
Practice Location
Address1: 1184 PEARL ST SW
Address2:  
City: WARREN
State: OH
PostalCode: 444853650
CountryCode: US
TelephoneNumber: 5672193045
FaxNumber:  
Other Information
ProviderEnumerationDate: 07/31/2015
LastUpdateDate: 07/31/2015
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
3747A0650X0132488OHN Nursing Service Related ProvidersTechnicianAttendant Care Provider
376K00000X0132488OHY Nursing Service Related ProvidersNurse's Aide 

ID Information
IDTypeStateIssuerDescription
013248805OH MEDICAID


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