Provider Demographics
NPI:1790030013
Name:JENKINS, JOHN R (DO)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
Last Name:JENKINS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 MEDICAL CIR
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD
Mailing Address - State:KY
Mailing Address - Zip Code:40351-1179
Mailing Address - Country:US
Mailing Address - Phone:606-783-6500
Mailing Address - Fax:606-783-6878
Practice Address - Street 1:222 MEDICAL CIR
Practice Address - Street 2:
Practice Address - City:MOREHEAD
Practice Address - State:KY
Practice Address - Zip Code:40351-1179
Practice Address - Country:US
Practice Address - Phone:606-783-6500
Practice Address - Fax:606-783-6878
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-24
Last Update Date:2020-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102203664207R00000X
KY04719207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100667890Medicaid
VA1790030013Medicaid
VAVVI208BMedicare PIN