Provider Demographics
NPI:1265468243
Name:JENKINS, LISA MICHELLE (MD)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MICHELLE
Last Name:JENKINS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 W 100TH ST RM 226
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-5145
Mailing Address - Country:US
Mailing Address - Phone:646-484-1295
Mailing Address - Fax:646-364-0780
Practice Address - Street 1:160 W 100TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-5145
Practice Address - Country:US
Practice Address - Phone:464-841-2956
Practice Address - Fax:646-364-0780
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA068681208000000X
NY217561208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0022217Medicaid