Provider Demographics
NPI:1609177641
Name:JENKINS, CHARLOTTE ANN
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:ANN
Last Name:JENKINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 CONCOURS STE 4200
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-6547
Mailing Address - Country:US
Mailing Address - Phone:480-600-2801
Mailing Address - Fax:
Practice Address - Street 1:3333 CONCOURS STE 4200
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-6547
Practice Address - Country:US
Practice Address - Phone:909-230-8930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-08
Last Update Date:2024-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95025124261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service