Provider Demographics
NPI:1568607281
Name:JENKINS, BRET IRA
Entity Type:Individual
Prefix:
First Name:BRET
Middle Name:IRA
Last Name:JENKINS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1647 S 1280 W
Mailing Address - Street 2:
Mailing Address - City:LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84321-6867
Mailing Address - Country:US
Mailing Address - Phone:435-512-6377
Mailing Address - Fax:
Practice Address - Street 1:1647 S 1280 W
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84321-6867
Practice Address - Country:US
Practice Address - Phone:435-512-6377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-09
Last Update Date:2008-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program