Provider Demographics
NPI:1376723106
Name:JENKINS, RUSTY L (PT)
Entity Type:Individual
Prefix:
First Name:RUSTY
Middle Name:L
Last Name:JENKINS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2233 ACADEMY PL
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-1696
Mailing Address - Country:US
Mailing Address - Phone:719-475-0808
Mailing Address - Fax:719-475-8822
Practice Address - Street 1:2233 ACADEMY PL
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-1696
Practice Address - Country:US
Practice Address - Phone:719-475-0808
Practice Address - Fax:719-475-8822
Is Sole Proprietor?:No
Enumeration Date:2007-11-08
Last Update Date:2011-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOA105451Medicare PIN