Provider Demographics
NPI:1598036071
Name:JENKINS, KRISTA E (PA)
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:E
Last Name:JENKINS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTA
Other - Middle Name:E
Other - Last Name:WELLENKAMP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:660 MASON RIDGE CENTER DR STE 300
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8512
Mailing Address - Country:US
Mailing Address - Phone:314-448-3791
Mailing Address - Fax:314-996-7658
Practice Address - Street 1:20 PROGRESS POINT PKWY STE 108
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63368-2207
Practice Address - Country:US
Practice Address - Phone:636-577-1493
Practice Address - Fax:618-498-7518
Is Sole Proprietor?:No
Enumeration Date:2012-01-16
Last Update Date:2024-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004248363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085004248OtherLICENSE NUMBER