Provider Demographics
NPI:1871912873
Name:JENKINS, EDDIE (LCSW)
Entity type:Individual
Prefix:
First Name:EDDIE
Middle Name:
Last Name:JENKINS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 OLIVE ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-2312
Mailing Address - Country:US
Mailing Address - Phone:318-429-7500
Mailing Address - Fax:318-227-6179
Practice Address - Street 1:856 TEXAS AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-3400
Practice Address - Country:US
Practice Address - Phone:318-426-8096
Practice Address - Fax:318-227-6179
Is Sole Proprietor?:No
Enumeration Date:2014-04-08
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1594101YP2500X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1417252230Medicaid