Basic Information
| Provider Information | |||||||||
| NPI: | 1720199524 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENKINS | ||||||||
| FirstName: | THEODORA | ||||||||
| MiddleName: | E | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4780 | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 474024780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8123361690 | ||||||||
| FaxNumber: | 8123491311 | ||||||||
| Practice Location | |||||||||
| Address1: | 650 N GIRLS SCHOOL RD | ||||||||
| Address2: | |||||||||
| City: | INDIANAPOLIS | ||||||||
| State: | IN | ||||||||
| PostalCode: | 462143672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3172715080 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 03/01/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 02001255A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | BR2936295 | 01 | DEA | OTHER | 02001255A | 01 | IN | IN LICENSE | OTHER | 02001255B | 01 | IN | CSR | OTHER |