Provider Demographics
NPI:1508877788
Name:JENCKS, CRYSTAL L (MD)
Entity Type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:L
Last Name:JENCKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CRYSTAL
Other - Middle Name:L
Other - Last Name:STRONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6920 POINTE INVERNESS WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-7934
Mailing Address - Country:US
Mailing Address - Phone:260-478-4201
Mailing Address - Fax:260-458-3248
Practice Address - Street 1:11115 LIMA RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46818-9536
Practice Address - Country:US
Practice Address - Phone:260-478-4201
Practice Address - Fax:260-458-3248
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11013271207Q00000X
IDM-12895207Q00000X
IN01066698207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200940480Medicaid
INM400037262Medicare PIN