Provider Demographics
NPI:1336269513
Name:JENKS, MICHAEL A (CPO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:JENKS
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2034 RANDOLPH RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1216
Mailing Address - Country:US
Mailing Address - Phone:704-377-7099
Mailing Address - Fax:704-377-7983
Practice Address - Street 1:2034 RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1216
Practice Address - Country:US
Practice Address - Phone:704-377-7099
Practice Address - Fax:704-377-7983
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Not Answered224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7703499Medicaid
NC7795013Medicaid