Provider Demographics
NPI:1538463666
Name:JENKINS, LISA W (CRNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:W
Last Name:JENKINS
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 SETON DR
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21502-1818
Mailing Address - Country:US
Mailing Address - Phone:301-722-3111
Mailing Address - Fax:301-722-5135
Practice Address - Street 1:912 SETON DR
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-1818
Practice Address - Country:US
Practice Address - Phone:301-722-3111
Practice Address - Fax:301-722-5135
Is Sole Proprietor?:No
Enumeration Date:2011-01-04
Last Update Date:2016-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR084836363LF0000X, 364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD552235800Medicaid
MD973435-02OtherBCBS POS
MD0224253OtherCIGNA
MD552235801Medicaid
MDW399 0013OtherBCBS FEDERAL
WV1538463666Medicaid
MD552235800Medicaid