Provider Demographics
NPI:1275506461
Name:JENKINS, ROGER CAIN JR (MD)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:CAIN
Last Name:JENKINS
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:172 E MERRITT ST STE C
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-2027
Mailing Address - Country:US
Mailing Address - Phone:928-717-0077
Mailing Address - Fax:928-717-0141
Practice Address - Street 1:172 E MERRITT ST STE C
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-2027
Practice Address - Country:US
Practice Address - Phone:928-717-0077
Practice Address - Fax:928-717-0141
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ34543207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ986721Medicaid
A44464Medicare UPIN
107132Medicare ID - Type Unspecified