Provider Demographics
NPI:1548202575
Name:JENKINS, LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:
Last Name:JENKINS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:675 W NORTH AVE
Mailing Address - Street 2:SUITE 408
Mailing Address - City:MELROSE PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60160-1634
Mailing Address - Country:US
Mailing Address - Phone:708-450-4950
Mailing Address - Fax:708-343-8505
Practice Address - Street 1:675 W NORTH AVE
Practice Address - Street 2:SUITE 408
Practice Address - City:MELROSE PARK
Practice Address - State:IL
Practice Address - Zip Code:60160-1634
Practice Address - Country:US
Practice Address - Phone:708-450-4950
Practice Address - Fax:708-343-8505
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036088632208600000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036088632Medicaid
ILG24156Medicare UPIN