Provider Demographics
NPI:1598917957
Name:JENKINS, KATHY MICHEL (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:MICHEL
Last Name:JENKINS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2675 WINKLER AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33901-9342
Mailing Address - Country:US
Mailing Address - Phone:877-856-3774
Mailing Address - Fax:
Practice Address - Street 1:3000 S MCCALL RD
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:FL
Practice Address - Zip Code:34224-8616
Practice Address - Country:US
Practice Address - Phone:941-406-9029
Practice Address - Fax:941-406-9028
Is Sole Proprietor?:No
Enumeration Date:2008-10-16
Last Update Date:2021-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005424363A00000X
FLPA9105586363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY0A7QOtherBCBS
FLGB659YMedicare PIN
FLGB659ZMedicare PIN
FL004859700Medicaid
FLPENDINGOtherAVMED