Provider Demographics
NPI:1639206576
Name:JENKINS, LESLIE C (ARRT, RPA)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:C
Last Name:JENKINS
Suffix:
Gender:M
Credentials:ARRT, RPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15831 N 1400TH ST
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-5210
Mailing Address - Country:US
Mailing Address - Phone:720-427-3016
Mailing Address - Fax:
Practice Address - Street 1:503 N MAPLE ST
Practice Address - Street 2:STE 300
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-2006
Practice Address - Country:US
Practice Address - Phone:217-340-1340
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes243U00000XTechnologists, Technicians & Other Technical Service ProvidersRadiology Practitioner Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04004826Medicaid
COH6408Medicare ID - Type UnspecifiedGROUP MEDICARE NO