Basic Information
Provider Information | |||||||||
NPI: | 1912900028 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JENKINS | ||||||||
FirstName: | MICHAEL | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1400 WALLACE BLVD | ||||||||
Address2: |   | ||||||||
City: | AMARILLO | ||||||||
State: | TX | ||||||||
PostalCode: | 791061708 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8064149970 | ||||||||
FaxNumber: | 8063564673 | ||||||||
Practice Location | |||||||||
Address1: | 1400 WALLACE BLVD | ||||||||
Address2: |   | ||||||||
City: | AMARILLO | ||||||||
State: | TX | ||||||||
PostalCode: | 791061708 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8064149970 | ||||||||
FaxNumber: | 8063513783 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/23/2005 | ||||||||
LastUpdateDate: | 02/26/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | H2493 | TX | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 200219360 A | 05 | OK |   | MEDICAID | P00115086 | 01 | TX | RRMEDICARE ID | OTHER | 853160 | 01 | TX | BCBS ID WITH GROUP | OTHER | V3692 | 05 | NM |   | MEDICAID | 128199006 | 05 | TX |   | MEDICAID | 128199003 | 05 | TX |   | MEDICAID | A018 | 01 | TX | CHAMPUS ID WITH GROUP | OTHER |