Provider Demographics
NPI:1710285929
Name:SCHENK, JEFFREY JACOB (DO)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:JACOB
Last Name:SCHENK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:JEFFREY
Other - Middle Name:JACOB
Other - Last Name:SCHENK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1303 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CEDAR CITY
Practice Address - State:UT
Practice Address - Zip Code:84721-9746
Practice Address - Country:US
Practice Address - Phone:435-868-5567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-11
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13018467-1204208M00000X
CO0053687207R00000X
NVDO1992207R00000X
CODR.0053687208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07307039Medicaid
COP01381223OtherRAILROAD MEDICARE
CO367091YL2GMedicare PIN