Provider Demographics
NPI:1558947069
Name:JENKINS, JESSE LANE (IDC)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:LANE
Last Name:JENKINS
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1734 COLD SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37683-4040
Mailing Address - Country:US
Mailing Address - Phone:423-440-9174
Mailing Address - Fax:
Practice Address - Street 1:1734 COLD SPRINGS RD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN CITY
Practice Address - State:TN
Practice Address - Zip Code:37683-4040
Practice Address - Country:US
Practice Address - Phone:423-440-9174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-23
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman