Provider Demographics
NPI:1407946205
Name:JERRY H. JENKINS, M.D., P.A.
Entity Type:Organization
Organization Name:JERRY H. JENKINS, M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:H
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:936-699-5040
Mailing Address - Street 1:1105 W FRANK AVE
Mailing Address - Street 2:SUITE 290
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3303
Mailing Address - Country:US
Mailing Address - Phone:936-699-5040
Mailing Address - Fax:936-699-5039
Practice Address - Street 1:1105 W FRANK AVE
Practice Address - Street 2:SUITE 290
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3303
Practice Address - Country:US
Practice Address - Phone:936-699-5040
Practice Address - Fax:936-699-5039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-13
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8603207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX124479006Medicaid
TX124479006Medicaid