Provider Demographics
NPI:1720786924
Name:JENKS, WESLEY
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:
Last Name:JENKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 OFFUTT RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:TN
Mailing Address - Zip Code:37716-6413
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:400 JL SEEHORN JR RD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37614-6504
Practice Address - Country:US
Practice Address - Phone:865-309-1202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-17
Last Update Date:2023-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNBACB890668156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist