Basic Information
| Provider Information | |||||||||
| NPI: | 1790030013 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JENKINS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 222 MEDICAL CIR | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403511179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067836500 | ||||||||
| FaxNumber: | 6067836878 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 MEDICAL CIR | ||||||||
| Address2: | |||||||||
| City: | MOREHEAD | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403511179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067836500 | ||||||||
| FaxNumber: | 6067836878 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/24/2012 | ||||||||
| LastUpdateDate: | 06/24/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0102203664 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 04719 | KY | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 7100667890 | 05 | KY | MEDICAID | 1790030013 | 05 | VA | MEDICAID |