Provider Demographics
NPI:1669240321
Name:JENKINS, KELCIE LEEANNE (PA)
Entity type:Individual
Prefix:
First Name:KELCIE
Middle Name:LEEANNE
Last Name:JENKINS
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 1:10900 S PENNSYLVANIA AVE APT 1532
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-4253
Mailing Address - Country:US
Mailing Address - Phone:918-764-5338
Mailing Address - Fax:
Practice Address - Street 1:9809 S PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73159-6925
Practice Address - Country:US
Practice Address - Phone:405-692-1557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-12
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK5163363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant