Provider Demographics
NPI:1669467700
Name:JENKINS, JOHN D (DC)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:D
Last Name:JENKINS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1981 MIDWAY RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:MENASHA
Mailing Address - State:WI
Mailing Address - Zip Code:54952-7001
Mailing Address - Country:US
Mailing Address - Phone:920-830-8700
Mailing Address - Fax:
Practice Address - Street 1:1981 MIDWAY RD
Practice Address - Street 2:SUITE A
Practice Address - City:MENASHA
Practice Address - State:WI
Practice Address - Zip Code:54952-7001
Practice Address - Country:US
Practice Address - Phone:920-830-8700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1820-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38781400Medicaid
WI75903Medicare ID - Type Unspecified
WI38781400Medicaid