Provider Demographics
NPI:1760888051
Name:JENKINS, MICAJAH
Entity Type:Individual
Prefix:
First Name:MICAJAH
Middle Name:
Last Name:JENKINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICAJAH
Other - Middle Name:
Other - Last Name:LLEWELLYN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6690 REGENCY DR SE
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98367-9514
Mailing Address - Country:US
Mailing Address - Phone:253-509-2176
Mailing Address - Fax:
Practice Address - Street 1:3497 BETHEL RD SE
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-5634
Practice Address - Country:US
Practice Address - Phone:360-874-9063
Practice Address - Fax:360-874-0071
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-13
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60031151183500000X
MT5692183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist