Provider Demographics
NPI:1245215318
Name:JENKINS, DARYL KINSHASA (DPM)
Entity Type:Individual
Prefix:DR
First Name:DARYL
Middle Name:KINSHASA
Last Name:JENKINS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9414 MEADOW VALLEY LN
Mailing Address - Street 2:# 104
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40291-3954
Mailing Address - Country:US
Mailing Address - Phone:502-327-8988
Mailing Address - Fax:
Practice Address - Street 1:775 WAUKEGAN RD
Practice Address - Street 2:SUITE 200
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-4342
Practice Address - Country:US
Practice Address - Phone:800-317-0711
Practice Address - Fax:800-434-7113
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-13
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN07000978A213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000333791OtherANTHEM BCBS
IN200256110Medicaid
INP00135072Medicare PIN
INV00315Medicare UPIN
IN200256110Medicaid