Provider Demographics
NPI:1205928660
Name:JENKINS, CHARLES C (MD)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:C
Last Name:JENKINS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 375
Mailing Address - Street 2:
Mailing Address - City:MENDOCINO
Mailing Address - State:CA
Mailing Address - Zip Code:95460-0375
Mailing Address - Country:US
Mailing Address - Phone:510-918-5296
Mailing Address - Fax:
Practice Address - Street 1:700 RIVER DR
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:CA
Practice Address - Zip Code:95437-5403
Practice Address - Country:US
Practice Address - Phone:707-961-1234
Practice Address - Fax:707-964-3691
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG9096174400000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1922031525Medicaid
CA1922031525Medicaid
CAGA483AMedicare PIN