Provider Demographics
NPI:1538664651
Name:JENKINS, M'KENZI ANN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:M'KENZI
Middle Name:ANN
Last Name:JENKINS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:M'KENZI
Other - Middle Name:ANN
Other - Last Name:BUTIKOFER-TORRES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMT
Mailing Address - Street 1:2162 WESTCLIFF CIR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83402-3896
Mailing Address - Country:US
Mailing Address - Phone:208-716-4110
Mailing Address - Fax:
Practice Address - Street 1:3345 POTOMAC WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-4978
Practice Address - Country:US
Practice Address - Phone:208-417-0090
Practice Address - Fax:208-417-0092
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-2860225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist