Provider Demographics
NPI:1508978750
Name:RUSSELL-JENKINS, SHANE B (MD)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:B
Last Name:RUSSELL-JENKINS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SHANE
Other - Middle Name:B
Other - Last Name:RUSSELL-JENKINS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2555 E GILA RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:YUMA
Mailing Address - State:AZ
Mailing Address - Zip Code:85365-2240
Mailing Address - Country:US
Mailing Address - Phone:928-317-9972
Mailing Address - Fax:
Practice Address - Street 1:2555 E GILA RIDGE RD
Practice Address - Street 2:
Practice Address - City:YUMA
Practice Address - State:AZ
Practice Address - Zip Code:85365-2240
Practice Address - Country:US
Practice Address - Phone:928-317-9972
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2004-01322084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM77456581Medicaid
NM343424400Medicare ID - Type Unspecified