Basic Information
| Provider Information | |||||||||
| NPI: | 1104170026 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENKINS | ||||||||
| FirstName: | DINA | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RDA | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 SNEATH LN | ||||||||
| Address2: | |||||||||
| City: | SAN BRUNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940662308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6502441444 | ||||||||
| FaxNumber: | 6502441447 | ||||||||
| Practice Location | |||||||||
| Address1: | 1001 SNEATH LN | ||||||||
| Address2: | |||||||||
| City: | SAN BRUNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940662308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6502441444 | ||||||||
| FaxNumber: | 6502441447 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2012 | ||||||||
| LastUpdateDate: | 02/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | R1360600819 | CA | N | Behavioral Health & Social Service Providers | Counselor | 101YA0400X | R1360600819 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.