Provider Demographics
NPI:1497438485
Name:JENKINS, JORDAN BRIAN
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:BRIAN
Last Name:JENKINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7506 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2066
Mailing Address - Country:US
Mailing Address - Phone:317-595-8964
Mailing Address - Fax:317-598-9651
Practice Address - Street 1:7506 N SHADELAND AVE
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46250-2066
Practice Address - Country:US
Practice Address - Phone:317-595-8964
Practice Address - Fax:317-598-9651
Is Sole Proprietor?:No
Enumeration Date:2023-08-08
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN26030456A183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist