Provider Demographics
NPI:1518958404
Name:JENKINS, KATHY (MD)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:
Last Name:JENKINS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 LONGWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5724
Mailing Address - Country:US
Mailing Address - Phone:617-355-7275
Mailing Address - Fax:603-893-8886
Practice Address - Street 1:300 LONGWOOD AVE
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5724
Practice Address - Country:US
Practice Address - Phone:617-355-2793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA72081208000000X, 2080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3114520Medicaid
MA604501OtherHARVARD PILGRIM
RIKJ03671Medicaid
NY1508016Medicaid
NC7613741OtherMEDICAID NC
MAB20216801OtherCIGNA MA
MA99085901OtherNETWORK HEALTH
NH300006034Medicaid
MA7500149OtherUNITED HEALTHCARE MA
MAJ14168OtherBCBS MA
MA3114520Medicaid
NY1508016Medicaid