Provider Demographics
NPI:1720199524
Name:JENKINS, THEODORA E (DO)
Entity Type:Individual
Prefix:DR
First Name:THEODORA
Middle Name:E
Last Name:JENKINS
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 4780
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47402-4780
Mailing Address - Country:US
Mailing Address - Phone:812-336-1690
Mailing Address - Fax:812-349-1311
Practice Address - Street 1:650 N GIRLS SCHOOL RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46214-3672
Practice Address - Country:US
Practice Address - Phone:317-271-5080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001255A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN02001255AOtherIN LICENSE
IN02001255BOtherCSR
IN02001255BOtherCSR
INM400032437Medicare PIN
BR2936295OtherDEA