Provider Demographics
NPI:1154952497
Name:JENKO, KIMBERLY JO (PA)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JO
Last Name:JENKO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:434 LEWIS ST NW
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180-4102
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5601 LOCH RAVEN BLVD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21239-2945
Practice Address - Country:US
Practice Address - Phone:410-532-3904
Practice Address - Fax:410-532-4599
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-27
Last Update Date:2020-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0007493363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical