Provider Demographics
NPI:1558247783
Name:JENKINS, TRAVIS DEAN
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:DEAN
Last Name:JENKINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4021 ALTAIR PL
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-1425
Mailing Address - Country:US
Mailing Address - Phone:208-520-2662
Mailing Address - Fax:
Practice Address - Street 1:1301 N A ST
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-3516
Practice Address - Country:US
Practice Address - Phone:805-742-3301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-13
Last Update Date:2025-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA240290978103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool