Provider Demographics
NPI:1093217218
Name:JENKINS, RANDON CARL
Entity Type:Individual
Prefix:
First Name:RANDON
Middle Name:CARL
Last Name:JENKINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6547 WINDMILL LN
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48324-3759
Mailing Address - Country:US
Mailing Address - Phone:313-516-7690
Mailing Address - Fax:
Practice Address - Street 1:4669 E 8 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48091-2709
Practice Address - Country:US
Practice Address - Phone:313-416-6262
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-03
Last Update Date:2018-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704273274363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology