Provider Demographics
NPI:1023083680
Name:JENKINS, SHANNON (DO)
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:
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 1:2860 CHANNING WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7531
Mailing Address - Country:US
Mailing Address - Phone:208-535-4575
Mailing Address - Fax:208-535-4569
Practice Address - Street 1:2860 CHANNING WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7531
Practice Address - Country:US
Practice Address - Phone:208-535-4575
Practice Address - Fax:208-535-4569
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2008-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ38632080N0001X
IDO04242080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0117377Medicaid
WY121542600Medicaid
ID121542600Medicaid
WY1285786046Medicaid
WY1285786046Medicaid
IDH80981Medicare UPIN