Provider Demographics
NPI:1144772237
Name:JENKINS, ALYSSA (PA-C)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:JENKINS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3820 CRESTWOOD LN
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-4979
Mailing Address - Country:US
Mailing Address - Phone:208-552-7700
Mailing Address - Fax:208-552-1786
Practice Address - Street 1:3820 CRESTWOOD LN
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404
Practice Address - Country:US
Practice Address - Phone:208-552-7700
Practice Address - Fax:208-552-1786
Is Sole Proprietor?:No
Enumeration Date:2016-10-25
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1436363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical