Basic Information
| Provider Information | |||||||||
| NPI: | 1730439647 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JENKINS FAMILY CLINIC, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 853 LAKESIDE DRIVE | ||||||||
| Address2: | |||||||||
| City: | JENKINS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 415370853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068320023 | ||||||||
| FaxNumber: | 6068320054 | ||||||||
| Practice Location | |||||||||
| Address1: | 853 LAKESIDE DRIVE | ||||||||
| Address2: | |||||||||
| City: | JENKINS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 415370853 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068320023 | ||||||||
| FaxNumber: | 6068320054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2012 | ||||||||
| LastUpdateDate: | 09/18/2012 | ||||||||
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| AuthorizedOfficialLastName: | COOK | ||||||||
| AuthorizedOfficialFirstName: | HEATH | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 6068320023 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.