Provider Demographics
NPI:1841230711
Name:JENKINS, JAY CARL (OD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:CARL
Last Name:JENKINS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6525A W HOUGHTON LAKE DR
Mailing Address - Street 2:
Mailing Address - City:HOUGHTON LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48629-9789
Mailing Address - Country:US
Mailing Address - Phone:989-422-5731
Mailing Address - Fax:989-422-2534
Practice Address - Street 1:6525A W HOUGHTON LAKE DR
Practice Address - Street 2:
Practice Address - City:HOUGHTON LAKE
Practice Address - State:MI
Practice Address - Zip Code:48629-9789
Practice Address - Country:US
Practice Address - Phone:989-422-5731
Practice Address - Fax:989-422-2534
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003630152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI13147OtherSPECTERA
MI230603OtherNVA
MI900G210200OtherBLUE CROSS BLUE SHIELD
MI943380807Medicaid
MI13146OtherSPECTERA
MIMI3630OtherEYEMED
MI1178430001OtherDMERC
MI410036674OtherRAILROAD MEDICARE
MIP35872FOtherBLUE CARE NETWORK
MI900022079OtherPRIORITY HEALTH
MI900G210200OtherBLUE CARE NETWORK
MI943380772Medicaid
MI900022079OtherPRIORITY HEALTH
MIP35872FOtherBLUE CARE NETWORK