Provider Demographics
NPI:1295985828
Name:JENKINS, GRETCHEN HEIDI (FNP-C)
Entity type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:HEIDI
Last Name:JENKINS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:128 N RANDOLPH ST
Practice Address - Street 2:
Practice Address - City:GARRETT
Practice Address - State:IN
Practice Address - Zip Code:46738-1138
Practice Address - Country:US
Practice Address - Phone:260-235-7655
Practice Address - Fax:260-357-0373
Is Sole Proprietor?:No
Enumeration Date:2008-09-18
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN090000144A367A00000X
IN71003049A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200946580Medicaid