Provider Demographics
NPI:1598954893
Name:JENKINS, LEJON J (IDC)
Entity Type:Individual
Prefix:
First Name:LEJON
Middle Name:J
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 1:25878 FRESCA DR
Mailing Address - Street 2:UNIT B
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-4951
Mailing Address - Country:US
Mailing Address - Phone:619-517-5945
Mailing Address - Fax:
Practice Address - Street 1:6555 BULLION AVE
Practice Address - Street 2:UNIT B
Practice Address - City:TWENTYNINE PALMS
Practice Address - State:CA
Practice Address - Zip Code:92277-3293
Practice Address - Country:US
Practice Address - Phone:619-517-5945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-23
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman