Basic Information
| Provider Information | |||||||||
| NPI: | 1568571438 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JENKINS | ||||||||
| FirstName: | BRAD | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11001 EXECUTIVE CENTER DRIVE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722114393 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5018127800 | ||||||||
| FaxNumber: | 5018127777 | ||||||||
| Practice Location | |||||||||
| Address1: | 2508 CRESTWOOD LANE | ||||||||
| Address2: | |||||||||
| City: | NORTH LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 721167623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5017582294 | ||||||||
| FaxNumber: | 5017587887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 11/19/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | E2046 | AR | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | E-2046 | AR | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207P00000X | E-2046 | AR | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7824049 | 01 | AR | AETNA | OTHER | 435276 | 01 | AR | HEALTHLINK | OTHER | 136241001 | 05 | AR | MEDICAID | 19145000040 | 01 | AR | QUALCHOICE | OTHER |