Provider Demographics
NPI:1639162811
Name:JENKINS, JACQUELINE M (OD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:M
Last Name:JENKINS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:JACQUELINE
Other - Middle Name:M
Other - Last Name:SANSONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:PO BOX 7079
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46207-7079
Mailing Address - Country:US
Mailing Address - Phone:317-278-1470
Mailing Address - Fax:
Practice Address - Street 1:1160 W MICHIGAN ST STE 100
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5209
Practice Address - Country:US
Practice Address - Phone:317-278-1470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1490152W00000X
IN18003487152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200881460Medicaid
TN1490OtherOD
TN3598926Medicaid
TN3598926Medicaid
TN3598926Medicaid
TN3598927Medicare ID - Type Unspecified
IN200881460Medicaid