Provider Demographics
NPI:1558247486
Name:JENKINS, RAQUEL
Entity type:Individual
Prefix:
First Name:RAQUEL
Middle Name:
Last Name:JENKINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 BROOKHILL CT
Mailing Address - Street 2:
Mailing Address - City:COLLINSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62234-6044
Mailing Address - Country:US
Mailing Address - Phone:314-915-3358
Mailing Address - Fax:
Practice Address - Street 1:13755 OLD HALLS FERRY RD
Practice Address - Street 2:
Practice Address - City:BLACK JACK
Practice Address - State:MO
Practice Address - Zip Code:63033-4129
Practice Address - Country:US
Practice Address - Phone:314-915-3358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-14
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO855544405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional