Basic Information
| Provider Information | |||||||||
| NPI: | 1346201316 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENKINS | ||||||||
| FirstName: | JULIA | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FOX | ||||||||
| OtherFirstName: | JULIA | ||||||||
| OtherMiddleName: | CLAIRE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 827 S JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | OSCEOLA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502131666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6413422128 | ||||||||
| FaxNumber: | 6413423179 | ||||||||
| Practice Location | |||||||||
| Address1: | 827 S JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | OSCEOLA | ||||||||
| State: | IA | ||||||||
| PostalCode: | 502131666 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6413422128 | ||||||||
| FaxNumber: | 6413423179 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/30/2006 | ||||||||
| LastUpdateDate: | 05/17/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 3581 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5452797 | 05 | IA | MEDICAID | 1346201316 | 05 | IA | MEDICAID | P00360611 | 01 | IA | RR MEDICARE | OTHER |