Provider Demographics
NPI:1174505432
Name:JENKINS, SHELLI A (NP-C)
Entity Type:Individual
Prefix:
First Name:SHELLI
Middle Name:A
Last Name:JENKINS
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1818 CAREW ST STE 260
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-4792
Practice Address - Country:US
Practice Address - Phone:260-373-9250
Practice Address - Fax:260-373-9262
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28099610163W00000X
IN71000494A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200375790Medicaid
IN000000376642OtherANTHEM BCBS
IN000000376642OtherANTHEM BCBS
P26738Medicare UPIN