Provider Demographics
NPI:1538464532
Name:JENKINS, KEYANNA A (LD)
Entity Type:Individual
Prefix:MS
First Name:KEYANNA
Middle Name:A
Last Name:JENKINS
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1610 GEM PL NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-2099
Mailing Address - Country:US
Mailing Address - Phone:541-686-9897
Mailing Address - Fax:541-485-3505
Practice Address - Street 1:1241 OAK ST
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-3519
Practice Address - Country:US
Practice Address - Phone:541-686-9897
Practice Address - Fax:541-485-3505
Is Sole Proprietor?:No
Enumeration Date:2011-01-21
Last Update Date:2011-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDT-DO-10138979122400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122400000XDental ProvidersDenturist