Provider Demographics
NPI:1801069752
Name:JERRY JENKINS II DPM
Entity type:Organization
Organization Name:JERRY JENKINS II DPM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:II
Authorized Official - Credentials:DPM
Authorized Official - Phone:256-331-3338
Mailing Address - Street 1:PO BOX 5268
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-5200
Mailing Address - Country:US
Mailing Address - Phone:256-331-3338
Mailing Address - Fax:256-331-2890
Practice Address - Street 1:533 GANDY ST NE
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AL
Practice Address - Zip Code:35653-1965
Practice Address - Country:US
Practice Address - Phone:256-331-3338
Practice Address - Fax:256-331-2890
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-10
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL221332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALDPM221Medicaid
AL1297050001Medicare NSC
AL000046151Medicare PIN
ALDPM221Medicaid