Provider Demographics
NPI:1649296278
Name:JENKS, JERRY DONN (OD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:DONN
Last Name:JENKS
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:79 MAPLE DR
Mailing Address - Street 2:PO BOX 1008
Mailing Address - City:PLATTE CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64079-9640
Mailing Address - Country:US
Mailing Address - Phone:816-858-3954
Mailing Address - Fax:816-858-3954
Practice Address - Street 1:79 MAPLE DR
Practice Address - Street 2:
Practice Address - City:PLATTE CITY
Practice Address - State:MO
Practice Address - Zip Code:64079-9640
Practice Address - Country:US
Practice Address - Phone:816-858-3954
Practice Address - Fax:816-858-3954
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT02268152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO310208160Medicaid
MO001091034Medicare ID - Type UnspecifiedIND #
MO01091033Medicare ID - Type UnspecifiedIND #
MOC401969BMedicare ID - Type UnspecifiedIND #
MO0480010002Medicare NSC
MOU05350Medicare UPIN
MO001091033Medicare ID - Type UnspecifiedIND #
MO000091233Medicare ID - Type UnspecifiedIND #
MO410019249Medicare ID - Type UnspecifiedRR MCR
MOC401969Medicare ID - Type UnspecifiedIND #
MO310208160Medicaid