Provider Demographics
NPI:1144415084
Name:ROGER JENKINS MD PLC
Entity Type:Organization
Organization Name:ROGER JENKINS MD PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:C
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:928-717-0077
Mailing Address - Street 1:172 E MERRITT ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-2026
Mailing Address - Country:US
Mailing Address - Phone:928-717-0077
Mailing Address - Fax:928-717-0141
Practice Address - Street 1:172 E MERRITT ST
Practice Address - Street 2:SUITE C
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-2026
Practice Address - Country:US
Practice Address - Phone:928-717-0077
Practice Address - Fax:928-717-0141
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34543207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ34543OtherLICENSE NUMBER
AZ34543OtherLICENSE NUMBER
AZA44464Medicare UPIN